23769	----	REPORT ON SURGERY TO THE SANTA CLARA COUNTY MEDICAL SOCIETY. BY J. BRADFORD COX, M. D. _READ MARCH 2d, 1880._ SAN JOSE: MERCURY STEAM PRINT. 1880. REPORT ON SURGERY. In presenting this report I will not attempt to give any historical data connected with the subject of surgery, since that has been ably done in the report of last year. I shall assume, and that without hesitation, that surgery is a science, properly so-called. That it is an art, is also true. But what is science? What is art? Science is knowledge. Art the application of that knowledge. To be more explicit, science is the knowledge we possess of nature and her laws; or, more properly speaking, God and His laws. When we say that oxygen and iron unite and form ferric oxide, we express a law of matter: that is, that these elements have an _affinity_ for each other. A collection of similar facts and their systematic arrangement, we call chemistry. Or we might say, chemistry is the science or knowledge of the elementary substances and their laws of combination. When we say that about one-eighth of the entire weight of the human body is a fluid, and is continually in motion within certain channels called blood vessels, we express a law of life, or a vital process. When we say this fluid is composed of certain anatomical elements, as the plasma, red corpuscles, leucocytes and granules, we go a step further in the problem of vitality. When we say that certain nutritious principles are taken into this circulating fluid by means of digestion and absorption, and that by assimilation they are converted into the various tissues of the body, we think we have solved the problem, and know just the essence of life itself. But what makes the blood hold these nutritious principles in solution until the very instant they come in contact with the tissue they are designed to renovate, and then, as it were, precipitate them as new tissue? You say they are in chemical solution, and the substance of contact acts as a re-agent, and thus the deposit of new tissue is only in accordance with the laws of chemistry. Perhaps this is so. Let us see as to the proofs. In the analysis of the blood plasma, we find chlorides of sodium, potassium and ammonium, carbonates of potassa, soda, lime and magnesia, phosphates of lime, magnesia, potassa, and probably iron; also basic phosphates and neutral phosphates of soda, and sulphates of potassa and soda. Now in the analysis of those tissues composed principally of inorganic substances or compounds, it will be seen that these same salts are found in the tissues themselves. So also the organic compounds lactate of soda, lactate of lime, pneumate of soda, margarate of soda, stearate of soda, butyrate of soda, oleine, margarine, stearine, lecethine, glucose, inosite, plasmine, serine, peptones, etc., are found alike in the tissues and in the blood plasma. That they are in solution in the plasma is well known,--that they are in a solid or precipitated form in the tissues is also true,--and that the tissues are supplied from the blood is also evident,--because the blood is the only part that receives supplies of material direct from the food taken and digested. That carbonate of lime and phosphate of lime are precipitated or assimilated from the plasma to form bone, is admitted by all physiologists. That the carbonates and phosphates already deposited act as the re-agent to precipitate fresh supplies from the plasma is not a demonstrated fact, but may be inferred. So also with the other tissues. Should this be admitted without positive evidence we would not then be at the end of our problem;--for the question may be asked as to what causes the first or initial deposit. Here we must stop and acknowledge our ignorance. But you may now ask what all this physiology and chemistry of the plasma has to do with a report on surgery. I propose to use it for the purpose of explaining some peculiarities in the process of repair in surgical cases. A few months ago I had a case of delayed union in a fracture of the tibia, at the hospital, and spent more time in waiting for nature, unassisted, to accomplish a cure, than I should ever spend again. One week after putting the patient on the use of ten grain doses of hypophosphite of lime, I had the pleasure of seeing bony union commencing. And why? Simply because the quantity of phosphate of lime in solution in the plasma was not sufficient to supply the waste of bone tissue in all parts of the body, and at the same time furnish a supply for the provisional callus which is thrown out in the repair of fractures. In September, 1878, August G----, aged 18 years, single, a native of Switzerland, was admitted to the Santa Clara County Hospital with incipient spinal disease. He was of that peculiar temperament which indicates a scrofulous cachexia. The fifth dorsal vertebra was sufficiently prominent to indicate the sight where the attack was being made by the enemy. There was considerable tenderness on pressure; slightly accelerated pulse, and elevated temperature;--in other words, a well defined case;--one which would have resulted in caries and deformity within a few months. By the administration of ten grain doses of hypophosphite of lime for several weeks, I had the pleasure of seeing recovery take place. Reasoning by analogy, I am led to conclude that the nature of the wound should, to a great extent, govern the kind of food given the patient during the treatment. In many cases of surgery, medicines are not necessary. But in some exceptional cases, as in similar ones to those above noticed, medicine is demanded. And in all cases of flesh wounds, I believe the patient will be benefited by a liberal diet of animal food; that is, after the first inflammatory condition has subsided. Why this is so, is simply because those very materials are furnished to the system which are required for the repair of the tissues injured, viz., the organic compounds. In flesh wounds of weak and debilitated persons which are slow in healing, a diet of beef tea, eggs, oysters, etc., will often bring about a rapid improvement. Thus, we see that chemistry, organic and inorganic, has something to do with surgery. I will now present the following cases which have seemed of special interest to me: CASE FIRST.--In 1874, while in the mountains on the Trinity river, Dr. ---- was kicked by a mule in such a manner as to rupture the ligamentum patellae. The tendon of the quadriceps femoris, at once drew the patella at least two inches above its normal position. Of course he was unable to walk, but was taken to a house near by. With some assistance from a brother physician the patella was brought down to its place, but it would not remain. I suggested the use of a gutta percha mould or covering for the knee. Without much difficulty, a piece one-fourth of an inch thick, softened in hot water, was applied, and kept in place by means of compresses and bandages until it hardened. This made a perfect and firm, splint fitting all the inequalities of the knee, covering all but the posterior part of the leg, and extending three or four inches above and below the patella. With this bound moderately tight to the leg by a roller bandage, it was simply an impossibility for the patella to move from its proper position. At the end of about a week the patient left the bed, and could walk about, but, of course, with a stiff leg. He wore this splint or cap for the knee for about four weeks, when I found he could leave it off at night without much pain. Continued to wear it during the day for perhaps a fortnight, when I found he could leave it off entirely. I mention this case partly for the purpose of calling the attention of the members of the society to the use of gutta percha as a material for splints. It is not adapted to all cases of fracture; but in very many cases I find nothing else so satisfactory. I have thought that in fracture of the patella it would be peculiarly valuable, as it is so readily adjusted to all the inequalities of the knee joint. CASE SECOND.--Jerome De----, aged fifty-four years, native of France, single, was admitted to the Santa Clara County Hospital, July 20th, 1878. He was suffering from rheumatism, or at least complained of pains in various parts of the body, more particularly the long bones of the arms and legs. These pains were worse at night, pulse varying between 80 and 90, temperature natural. Suspecting a specific origin for this malady, I put him on the use of iodide potassium, with increasing doses. He slowly improved with the exception of a pain in the left humerus, anteriorily, and in the upper part of the middle third. This became localized to a spot no larger than a twenty-five cent piece. At times the pain was intense and excruciating: and about a week from admission this spot seemed quite tender to the touch. After the use of a blister and tincture of iodine for a week, he was somewhat relieved. Not entirely, however, for at times the pain was very severe. On Aug. 7th, he left the hospital thinking he could do some work. The next day, while attempting to climb a fence, and while in the act of raising the body by the arms, the left humerus was fractured transversely at the exact point of his previous suffering. He was again admitted to the hospital, and the fracture dressed in the usual manner. After five or six days a gutta percha splint was used which encircled the arm. Bony union was slow in taking place. However, on Oct. 3d, nearly two months from the date of the fracture, he left the hospital, the union being complete, and he being entirely relieved from his pain; in fact, he was relieved from the moment of the fracture. This case presents a question in pathology which is of interest. Was there a localized periostitis at this point? If so, why was it not entirely relieved by the treatment which consisted of blisters and iodine, externally, and mercury and iodide potassium internally? Was there a deficiency of nutrition at this point? or anemia from some change in the nutrient artery,--the result of the periostitis of the long bones? Or was it incipient necrosis? Prof. Hamilton gives the record of a case of fracture of the humerus, from muscular action, taking place three several times in the same individual, each time in a different place. CASE THIRD.--Dec. 29th, 1878, was called to see Mr. ----, male, married, aged about 40 years. Has led an out-door, active life. Has always been healthy. No venerial taint. Nervous temperament, spare built, and weighs about 140 pounds. Present condition: Has been sick two or three days; the attack commenced with a chill, followed by fever; has had fever ever since the chill; complains of pains in the back and legs; has vomited considerable; bowels costive; tongue coated; severe pain in right side corresponding to lower part of the lung, which I found solidified; there is considerable cough. Ordered a cathartic; to be followed by an anti-pyretic of acetate of ammonia and aconite, and a blister over the lower part of the right lung. Continued this treatment for three or four days, when the pneumonia began to subside, and at the end of about ten days I considered my patient convalescent. About this time I was sent for in great haste after night. The patient, who is a very intelligent man, said he had felt worse during the day, and in the evening, his knee, which had been somewhat painful for two or three days, had become exceedingly painful. I gave morphine, hypodermically, and went home, leaving some morphine for the night. The next day I saw him. The pain had been relieved by the morphine, still occasionally it was quite severe. There was no redness or heat, or even tenderness; nothing unnatural about the knee except pain, which was aggravated by any attempt to move the leg. Ordered quinine as a tonic, and pill "C. C." as a cathartic. Bandaged the leg pretty tightly from the toes to above the knee. The urine was natural; pulse and temperature only slightly elevated. After six or seven days of these symptoms, the knee began to feel hot and became very slightly swollen. Ordered a small blister over the inside of the knee as the greatest amount of pain seemed to be here. Dressed it with tartar-emetic ointment until the skin was very sore; using iodine on other puts of the knee. Used iodide potassium and colchicum, internally. This treatment for five days seemed to do no good. On Jan. 17th, twenty-two days from the beginning of his illness, and about twelve days from the first appearance of symptoms denoting any local trouble at the knee, a consultation was held, the result of which was a blister over the whole of the knee, to be dressed with unguentuin hydrargiri. The inflammation was but little influenced by this or any other treatment. The knee continued to slowly and surely enlarge. And this extended upward without first producing any great distention of the synovial sack under the patella. There seemed to be simply enlargement of all the tissues of the lower part of the thigh. This continued until about the 1st of Feb. when, from the general appearance of the patient, viz: a typhoid condition, feeble pulse, coated tongue, emaciation, loss of appetite, as well as from the local appearance of the inside of the knee, I suspected pus within the joint. Accordingly, I introduced an exploring needle into the inner part of the joint just above and anterior to the insertion of the tendon of the semimembranosis muscle. Finding pus, I made an incision only about half an inch long, and squeezed out perhaps an ounce of pus. Closed this up and again bandaged the leg. There was but very little pus discharged from this opening afterward, not, however, for want of drainage, since the cut was kept open by introducing the probe occasionally. About the 9th or 10th of Feb. fluctuation became quite apparent along the outer and lower part of the thigh. On Feb. 12th, consultation was again had, when fluctuation being very well marked over a considerable portion of the thigh in its lower and middle thirds, after giving the patient chloroform, an incision was made three inches long on the outer and posterior part of the thigh, from the junction of the lower with the middle third, downward through the posterior part of the vastus externus muscle. About two quarts of laudable pus was discharged. By introducing the finger upward and downward, the periostium could be felt smooth except within the knee joint, for this could be distinctly felt, the finger passing readily between the ends of the femur and tibia, and beneath the patella; the crucial and lateral ligaments seemed to be gone, and the cartilages somewhat roughened. A drainage tube was put in, the leg bandaged from the toes to the trochanter major, with compresses so arranged as to obliterate the sack, if possible. The patient, up to this time, had been slowly losing flesh, and was now very much emaciated. A general typhoid condition existed, the temperature ranging from 101 to 103.5; the pulse from 115 to 135, tongue coated, poor appetite, and in short, the patient in a very critical condition. The use of chloroform, and the shock from the evacuation of the pus, added to the gravity of all the symptoms, and for about two weeks the patient was in great danger of death from asthenia. However, by liberal use of whisky, quinia, beef tea, cod liver oil, etc., he slowly rallied. Two smaller abscesses formed below the knee, but those gave no great anxiety, not so much as some bed sores on the back and hips. The sack or pouch became gradually obliterated, down as far as the knee. The cavity of the joint, however, did not seem to be well drained from the opening in the thigh, notwithstanding it had been kept open freely by tents. About three weeks from this last operation, the sinus or pouch within the knee-joint being so imperfectly drained as above indicated, I made an opening directly into the joint at the outer and posterior part, one inch long, through which I could introduce the probe between the ends of the femur and tibia, without any difficulty, through all parts of the joint. However, I discovered no necrosed bone by so doing. Put a tent into this opening, and let the one above heal up, which it did in about two weeks. This latter opening into the joint I kept open by means of tents until the joint became anchilosed and ceased to discharge pus. The patient made a slow and steady recovery, and about the middle of April was able to get out doors again. The special points of interest in this case seem to be the obscure and insidious mode of attack; the slow progress of the inflammation, it being rather sub-acute than acute; and the fact of its being a sequela of pneumonia. Prof. Gross, in his excellent work on surgery, says, "synovitis, in the great majority of cases, arises from the effects of rheumatism, gout, eruptive fevers, syphilis, scrofula, and the inordinate use of mercury." Prof. Hamilton, in "Principles and Practice of Surgery," says, "synovitis may be caused by exposure to cold, or may occur as a consequence of a rheumatic, strumous, or syphilitic cachexia, as a gonorrhoeal complication, as a sequela of fevers, and from many other causes, whose relation to the disease in question may not always be easily determined." Since there was no local injury to the knee in this case which could have caused the disease, we must seek some other cause for it. I have thought that its origin might be accounted for on the principle of metastasis of morbid material. The patient had pneumonia which passed through its several stages somewhat rapidly, resolution taking place about the end of the second week. The symptoms of this were well marked, viz: a chill followed by fever, cough, brick-dust sputa, delirium, pain over lower half of right lung, which was solidified, and afterward gave the crepitant and sub-crepitant roles. Could not the morbid material, which entered the circulation from the re-absorption of the deposit in the solidified lung, have been carried to the synovial membrane of the knee, and there found a lodgment, and set up the inflammation which resulted in the formation of so much pus? If not, Why not? Notwithstanding a tedious illness, and an anchilosed knee, was not this result better than to have had suppuration of the lung tissue and destruction of the whole of the right lung, and perhaps eventually the left also? However, we are not certain that such a result would have followed, although the patient's general appearance at the time of the attack, and the typhoid condition which followed, as also the low grade of inflammation bordering on the scrofulous, made such a thing probable. CASE FOURTH.--On Jan. 31st, 1879, Mr. R----, Italian, aged 35 yrs., while chopping wood near Almaden mines, was injured by a falling tree. The lower part of the body was very much bruised, both posteriorly and anteriorly. The only place where the skin was broken was a smooth cut about four inches long and nearly half an inch deep, following the fold or crease between the right testicle and thigh, and extending from the anterior part of the testicle to the perineum in a straight line just where the scrotal integument joins that of the thigh. The main injury was in the lumbar region over the upper lumbar vertebræ. The spinous process of the lower dorsal vertebra seemed to be unusually prominent, leading to the supposition that the spinous process of the upper lumbar vertebra might be fractured and depressed. However, I was unable to detect mobility or crepitus in any of the processes, spinous or transverse, either of the dorsal or lumbar vertebræ. There was considerable tenderness over the lumbar region. I would here state that the examination was made about twenty hours after the receipt of the injury. There was but little discoloration of the skin, not very much pain, no paralysis of any part, the bladder evacuating itself naturally, and a cathartic producing its ordinary effect in the usual time. The patient did well; complained of but little pain; did not use opiates. On Wednesday and Thursday following, the patient felt well enough to walk about the wards, eating well and having no constitutional disturbance, pulse never higher than eighty per minute, and the temperature not above 99 degrees F. On Friday morning the nurse remarked that this patient had complained of pain in the back during the previous night, and that there seemed to be a soft spot on his rump. By examining, I found below the bandage which I had put around the patient, a fluctuating mass, immediately beneath the skin and superficial fascia, extending from the tenth dorsal vertebra above, to the coccyx below, and from the crest of the right ilium to that of the left. I was at a loss to know how to account for this fluid, for there was at least a quart. I removed the bandage and examined more carefully. There was no inflammation to amount to anything, nor had there been. Here it is only the seventh day from the receipt of the injury, and it surely cannot be pus. However, to satisfy myself, I used an exploring needle; and not very much to my surprise, I discovered light colored arterial blood! Could I be mistaken? I twisted the needle about, pressed it to one side, until nearly a drachm of the blood had escaped. Fully convinced now that I had a secondary hemorrhage to deal with, the question arose what to do. I supposed that it came from one of the lumbar or inter-costal arteries that had been injured by the supposed fracture of the process of the vertebra. If so, it comes from an artery inclosed in a bony cavity, and one that cannot contract and close spontaneously, and since its origin is so close to the aorta, it will continue to bleed until the patient dies of hemorrhage. While I was thus examining the fluctuating mass, and conjecturing as to origin and results, I fancied that the quantity of fluid was sensibly increasing. However, I will not be positive that my imagination did not assist in this accumulation. But what shall I do? Cut down into this sinus, and hunt the bleeding artery, and tie it? Could I find it? And could I tie it if I did find it? Probably not; and more especially if it is a lumbar artery, and injured in the foramen through which it passes from the vertebra. But the man will probably bleed to death; and must I do nothing to prevent it? I concluded to use pressure with a bandage for the present, and ask for the advice of my brethren. Accordingly, compresses were placed along the spine, and the body bandaged snugly. On returning to town, I stated the case to doctors Brown and Thorne, giving my theory for the hemorrhage,--that it was secondary, and probably from a lumbar artery. They were of opinion that it would be almost an impossibility to find the artery and tie it, and without seeing each other, concluded that pressure was the remedy to be used. I would state that at the last visit the pulse was 74, and temperature 99. This was at about 9 A. M. I visited him again about 5 P. M., and found the pulse and temperature the same. There was by this time considerable increase in the quantity of fluid. I re-adjusted my compresses and bandaged again. On Saturday morning I found the quantity of fluid about the same, perhaps slightly increased. There was now considerable inflammation of the integument, over a large part of the sinus, the skin appearing tense, and the small blood vessels distinct and purple. The patient had a slight chill last night, pulse 100, temp. 102; did not remove the compresses. Saturday evening, Feb. 7th, condition worse, pulse 112, temp. 103, tongue furred ash-colored, countenance typhoid in expression, loss of appetite, no abdominal symptoms, mind clear. Sunday, Feb 8th. pulse 120, temp. 105.4, tongue same as yesterday, had a chill last night. The skin over the sinus is inflamed somewhat more than it was yesterday. With the advice and assistance of doctors Brown, Thorne, Benj. Cory and Kelly, sixty-eight ounces of blood was removed from the sinus, by aspiration. One hour after this operation, the pulse was 140 and the temp. 104. The specific gravity of the blood removed was 1030, and after standing for two or three hours, a grey or ash-colored sediment settled, the proportion of this being about 20 per cent. of the whole amount of the blood. This sediment consisted of corpuscles that seemed to be undergoing decomposition; they were a little larger than the red corpuscles; contained granules or spots, from three to four and seven and eight in each corpuscle. Some of them seemed to be simply swollen red blood corpuscles, ready to burst, or as it were, suppurate. If there be such a thing as inflammation of the blood,--and I believe there is,--then this change must effect the red corpuscles themselves, as to size, temperature and perhaps pain, thus supplying three of the well known characteristics of inflammation, expressed so tersely by the old latin formula, _rubor, tumor, calor cum dolore_. Owing to the color of the blood, the rubor, or redness, is not produced by inflammation here as it already exists. But to return to the patient. After the blood was withdrawn, compresses were carefully applied, and the body bandaged from the lower ribs as low down as the bandage could be applied with the legs flexed at right angles to the body. The patient stood on all fours, as it is called, while the bandage was applied. Monday, Feb. 9th, 9:30 A. M., pulse 100, temp. 103.8. There appeared to be about one-half a pint of fluid in the sack. Monday, Feb. 9th, 6:30 P. M., pulse 100, temp. 102. Tuesday, Feb. 10th, 9:30 A. M.,--the fluid in the sack has increased--perhaps a pint now in it, pulse 110, temp. 104. Wednesday, Feb 11th, 9:30 A. M.,--pulse 90, temp. not taken. Condition good. Ordered a laxative. Friday, Feb 13th,--considerable inflammation over the left iliac crest, in the centre of which, a spot as large as the thumb nail, looks gangrenous. The inflammation extends over a surface as large as the two hands. Some bullae or blebs have formed in the vicinity of the gangrenous spot. Ordered a large flaxseed poultice applied, expecting an abscess would form at this place. The cathartic moved the bowels two or three times. I will here state that the patient, after the withdrawal of the blood on Sunday, was ordered iron, quinine and whisky; twenty minims of Tr. Ferri Muriat., three grs quinia, in a tablespoonful of glycerine and a little whisky. I afterward had the quinia made into pill and left off the iron, as the latter seemed to disagree with the stomach. Saturday, Feb. 14th, 5 P. M.,--pulse 112, temp. 102.4. The inflammation over the left ilium is much better; but there is now as much inflammation over the right ilium as there was over the left. The fluid in the sinus has increased gradually since the evacuation of it with the aspirator. The inflammation that has now existed for two or three days over these parts of the sinus, led me to conclude that the blood which was left and that which had accumulated, had undergone decomposition and was now pus. I used an exploring needle and found this to be the case. I then introduced a trocar and canula, and drew off fifty ounces of pus, slightly tinged with blood. I re-adjusted the compresses and bandage over the sinus, hoping that a part of it at least would become obliterated before it became necessary to open it more freely. Feb. 15th, 5 P. M.,--pulse 112, temp. 102.5. The inflammation over that part of the sinus to the right of the spine is still about the same as yesterday; also that over the left ilium. The fluid has increased during the last twenty-four hours so that there is now nearly as much as was drawn off through the canula yesterday. I concluded that further delay to a free opening was useless; consequently with the patient lying on his right side, and near the edge of the bed, I made an opening one inch long in the lower portion of the abscess,--for I now considered it one,--near the spot where the needle of the aspirator and the trocar had been previously introduced. After the discharge of about a pint of bloody pus, the stream was checked by a clot of blood coming into the opening. I enlarged the opening, making it about two inches long, when a clot the size of a hen's egg came through, followed by about a pint more of bloody pus. After syringing the cavity with a five per cent. solution of carbolic acid in distilled water, and introducing a tent about four inches long, I applied compresses and bandages. Ordered the quinia continued, and whisky and beef tea. Feb. 16th, 9 A. M.,--pulse 100, but feeble; temp. 97.8. Removed dressings which were saturated with pus and blood. The latter had excited the anxiety of the Superintendent during the night, and he applied an additional bandage. There was perhaps five or six ounces of thick, flaky, yellow pus discharged. No hemorrhage; syringed the cavity with a five per cent. solution as before, and introduced a clean tent. On examining the inflamed spot over the left ilium, I detected fluctuation over the anterior part of the crest of the ilium, near the gangrenous spot, and extending down over the abdomen. However, it seemed to be superficial, at least, not deeper than the connective tissue between the external and internal oblique muscles, and not more than one inch by two in size. This I opened, and squeezed out about half a ounce of pus. Introduced a tent and applied oakum over both tents, for the purpose of absorbing the pus, and applied a compress over the main sinus or pouch, and a bandage over the whole lower part of the body. Feb. 17th, 9 A. M.,--pulse 96, temp. 99. Ordered a laxative of carbonate of magnesia. Both openings discharging very freely. The gangrenous spot over the left ilium is separating from the surrounding tissues. Removed considerable dead flesh from this spot, leaving an opening or pouch one inch in diameter, leading down to the pubis, just beneath the oblique muscles. Feb. 19th, 9 A. M.,--pulse 106, temp. 99.5. Both sinuses discharging very freely. Made an opening in the lower part of the pouch to the left of the pubis for better drainage, as the patient usually lies on the right side. Laxative has operated. After washing out both sinuses with a five per cent. solution of carbolic acid, I inject the smaller sinus with liquid vasaline. Feb. 20th, 9 A. M.,--pulse 112, temp. 103.5. There is a great amount of pus being discharged from the large sinus on the back, not so much from the small one. Patient had a chill last night. After the usual washing out of the sinuses with the carbolic solution, I inject both of them in with liquid vasaline. This I do, a well as the washing out, by means of a No. 10 catheter, attached to the end of a Davidson's syringe. The sinus on the back extends from the coccyx to the ribs, and from one ilium to the other. The skin and fascia of the external wall being so thin that the catheter can be seen over the entire extent, as I push it from one part to another for the purpose of washing out all parts of the sack. Patient has been complaining of pain and want of sleep; had a chill last night. He still takes beef tea twice a day, and eggs and other food twice a day, making four meals a day; also, continues the quinine and whisky. Feb. 21st, 9:30 A. M.,--pulse 98, temp. 101. Feels more comfortable. Discharge of pus much less than yesterday. Wash out the sinuses and inject liquid vasaline. Feb. 23d, 9:30 A. M.,--pulse 98, temp. 101. Complains of being "very sick." Speaks English but poorly. Considerable discharge of laudable pus, but not so much as before the use of the liquid vasaline. There is one point near the left hand side of the large sinus on the back, where the walls are adherent. I wash them out with a five per cent. solution of carbolic acid in water, and again inject the liquid vasaline. By gentle pressure made over the upper part of the pouch, I force everything out of it at the opening below, bringing the walls of the sack together over the greater part of the surface. Hoping that the adhesion between the walls, which has commenced, will continue, and soon obliterate, at least, all the upper part of the pouch. Put on the usual compresses; this time using oakum instead of folded cloths. Feb. 24th, 9:30 A. M.,--pulse 108, temp. 101. Did not wash out the upper or left hand part of the pouch on the back, for fear of disturbing adhesions that are taking place. Washed out the lower part and injected vasaline. A small spot, as large as a ten cent piece, has sloughed, making a hole into the pouch over the lower lumbar vertebra. Another spot immediately above this, and about the same size, looks as if it would slough. Feb. 25th, 9:30 A. M.,--pulse 100, temp. 100. Feb. 27th, 9:30 A. M.,--pulse 115, temp. 99.2. Adhesion is taking place between the walls of the sinus, on the left of the vertebræ. Feb. 29th, 9:30, A. M.,--pulse 104, temp. 100. The sacks, or sinuses, have been washed out regularly every day, and dressed with vasaline. This case presents several features of interest. The first is the very large amount of secondary hemorrhage, and its location, there being sixty-eight ounces removed at one time and fifty at another, and perhaps thirty or forty at another, from just beneath the skin and superficial fascia of the lower part of the back. The second point of interest would be to know from what vessel this hemorrhage took place. The third interesting feature of the case is its progress and treatment. At the time of the aspiration the patient was in a critical condition; temp. 105.4, pulse 120; the tongue and chill denoting danger of pyemia. This danger was avoided by drawing off the decomposing blood, and giving the patient a new lease of life. This was but temporary, for six days afterward the same danger presented itself again. This was also avoided by opening the sinus freely, by an incision two inches long, which could not have been done sooner for fear of adding to the hemorrhage. At the end of six days from this last critical period, the temperature again went up to 103.5, and the pulse and condition of the patient indicated great danger of death from exhaustion--the result of the formation of so much pus. This was avoided by preventing the excessive formation of pus by washing out the sinus with liquid vasaline. The patient is still under treatment in the hospital now under the care of my esteemed friend, Dr. Benj. Cory. The patient will probably recover. It will be simply a question of endurance with him. That is, if the supply of nourishment can be kept up, and the waste prevented, which must result from the formation of such a large quantity of pus, there is no reason why he should not recover.[A] [A] On March 25th, date of publication of this report, the patient is considered convalescent. At the time of putting him under the care of Dr. Cory, he was taking nine grains of quinia daily, about six ounces of whisky, beef tea twice a day, and eggs twice, with such other food as he might relish; taking four meals a day. Thus you see I was carrying out the theory mentioned in the first part of this paper:--that of supplying the system with all the flesh producing food the stomach would digest, and using whisky and quinia to prevent disassimilation or waste; also vasaline locally for a similar reason. With this case I conclude my report; only adding that perhaps the thought of a poet, who evidently knows much of human nature, is applicable to this hastily written paper. This poet says: "A fool will pass for such through one mistake, While a philosopher will pass for such, Through said mistakes being ventured in the gross And heaped up to a system." Thus I, as one or the other of the personages here mentioned, offer this, my mite, to the literature of surgery, leaving you to decide which of the titles I deserve. 
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57083	----	THE BARBARITY OF CIRCUMCISION AS A REMEDY FOR _CONGENITAL ABNORMALITY_ BY HERBERT SNOW, M.D. LOND. &c. SURGEON TO THE CANCER HOSPITAL [Illustration: Logo] LONDON J. & A. CHURCHILL 11 NEW BURLINGTON STREET 1890 PREFATORY NOTE To state that the object of this little work is to 'put down Circumcision' under the circumstances indicated, would, besides savouring of unpardonable arrogance, irresistibly suggest analogy to the example of a too famous alderman, who was determined to 'put down Suicide.' If, however, the facts and arguments therein set forth contribute in some small measure towards the abolition of an antiquated practice involving the infliction of very considerable suffering upon helpless infants; and sanctioned, on extremely questionable grounds, by men of eminent authority; the following pages will not have been written in vain. More evil is wrought by want of thought, Than comes from want of heart. GLOUCESTER PLACE, PORTMAN SQUARE: _October 1890_. THE BARBARITY OF CIRCUMCISION AS A REMEDY FOR CONGENITAL ABNORMALITY. I CIRCUMCISION AS A RELIGIOUS RITE. The earliest historical or quasi-historical notice of circumcision is to be found in Genesis xvii.; where Jahve enjoins upon Abraham the personal performance of this mutilation, as a sign of the covenant henceforward to subsist between them. Abraham, his son Ishmael, and all his male slaves forthwith underwent the prescribed operation; which thence-forward remained obligatory upon their posterity, though not without transient periods of desuetude. It was suffered to lapse during the passage of the Israelites through the wilderness, and was subsequently revived by Joshua (v. 5); again in the reign of Antiochus Epiphanes, when some of the Jews seem to have submitted to a plastic operation in order to obliterate its effects.[1] The compulsory performance of circumcision was re-enacted for the last time by Mattathias, in the age of the Maccabees; and the law to this effect has remained in force until the present day.[2] The terms in which the Deity addresses his commands to Abraham presuppose an already existing familiarity with the ritual ceremony on the part of the latter. Accordingly we find that it previously prevailed among the Colchians, Æthiopians, and ancient Egyptians of both the Upper and Lower Provinces (Gardner Wilkinson). Among the latter it appears to have become restricted, by the dawn of the historical period, to the priestly caste, and to those who desired initiation into the sacred mysteries. In the temple of Chunsu at Karnak is a delineation of the rite as performed on two young children, probably sons of Rameses II., the founder of the building. It was apparently connected with the worship of Ra, the Sun God; and a seeming allusion to it in this connection is to be found in chapter xvii. of the 'Book of the Dead.' Notices of circumcision also appear in ancient Phoenician mythology. There can be no question of its very great antiquity, or of its wide prevalence among ancient nations. Traditional descent from a primæval Stone Age is betrayed by casual notices in Holy Writ. Thus, in Exodus iv. 25, a sharp stone is the instrument of mutilation; and in Joshua v. 2, the marginal rendering is 'knives of flints.'[3] The Hivites, the Canaanites (Phoenician), and many if not most of the nations with whom the Israelites were brought into contact after settlement in the Promised Land, appear to have practised circumcision at some period in their history. In the Old Testament we accordingly find the designation of 'the uncircumcised' specially reserved for the Philistines, and applied to these as a term of opprobrium. The list of peoples by whom the circumcision of males has been, or is still, an established custom is sufficiently long. Among such races at the present day, 'an almost unbroken line may be traced from China to the Cape of Good Hope,' and unless perhaps in Europe (where comparatively slight traces of aboriginal manners and customs survive), we find the ceremony characteristic not only of savage tribes, but of nations ranking fairly high in the scale of civilisation; for instance, the Mexicans, and the ancient Aztec races of Central America. The Teanas and Manaos on the Amazon; the Salivos, Guamos, Otamocos, on the Orinoco; the negroes of the Congo, with many other tribes on both the west and east coasts of Africa, notably the Kaffirs, Bechuanas, and Hottentots; the Abyssinians (Christian), Nubians and modern Egyptians; the natives of Madagascar; most of the Australian aborigines; the Papuans, New Caledonians, inhabitants of the New Hebrides, of Java, of the Philippines, and of Fiji, are only a few that may be indicated. An approximation to the rite in the form of a slitting up of the prepuce was noticed among the Friendly Islanders by Captain Cook. Although not enjoined in the Koran, it is a universal practice among the Mohammedans, as a tradition from the ante-Mohammedan period. A cognate operation upon _females_ obtains among the modern Egyptians, the Nubians, the Abyssinians, as well as in many other parts of Africa among the negro races; also among the Malays on the shores of the Persian Gulf (Carsten Niebuhr), and on the banks of the Orinoco. As an ancient custom in Arabia and Egypt, it is noticed by Strabo. Local variations of detail are found; as in the case of the Friendly Islanders just cited; and of the Madagascarians, who cut the flesh at three several times; the excised prepuce being eventually _swallowed_ by some relative or other. The date at which circumcision is performed varies considerably. Among the Jews, the eighth day is, of course, the selected period; probably from consideration for the sacred number seven, for the seven days of uncleanness prescribed for the parturient mother (Lev. xii. 2), and for an idea that with the second cycle of seven days the infant then properly commenced its earthly life. Among the Arabs, it is deferred till the thirteenth year; the age at which their reputed ancestor, Ishmael, was submitted to it. And every race seems to have selected for itself what was considered the most suitable time. The Turks, for example, have chosen the seventh or eighth year; the Persians circumcise boys at thirteen, girls, between the ninth and the fifteenth year; and so on. It is thus evident, not only that the rite is extremely ancient, but that it is impossible to refer the practice of circumcision to any single source; or to doubt that it originally arose among many widely-sundered peoples, as the result of a certain stage in man's mental evolution. The once widely-spread custom of the COUVADE, and other strange aboriginal practices, afford an illustrative analogy.[4] Herodotus seems to have been the author, or at least the introducer, of the cleanliness theory; according to which the ceremony was invented from motives of hygiene. Philo Judæus ascribes the custom to four causes: 1. Cleanliness; 2. The avoidance of carbuncle (Qu. cancer?); 3. The symbolisation of purity of heart; 4. The attainment of numerous offspring. Of these, it need hardly be said that the last has no foundation in fact; and the two preceding require no remark. The idea, however, that circumcision was initiated for purposes of cleanliness has lasted to the present day, and still appears to have considerable currency. Whatever may have been the social condition of the ancient Egyptians and Arabians, on behalf of both which races, as having been the source whence Abraham derived his evident familiarity with the custom, plausible pretensions have been put forth; it is simply preposterous to imagine for a moment that the numerous savage tribes (witness the Hottentots and the Australian aborigines) who practise it, could ever have been actuated by any such considerations. Its world-wide diffusion, again, totally forbids the supposition, either of its introduction into these tribes by contact with other nations more highly civilised; or of its adoption, by the former, while in a higher stage of sociology, from which they have subsequently become degraded. And this explanation is put finally out of court by the phenomenon of an analogous rite applied in sufficiently numerous quarters to the persons of females. In order, therefore, plausibly to account for the general prevalence of this strange mutilation, we are compelled to look elsewhere; and an examination of the religious ideas which are known to actuate primitive man, will afford a clue. Copious illustrations of the working of such ideas among peoples emerging from barbarism can be traced in almost every page of the earlier books of our Old Testament; and, even in classical mythology, although overlaid by the later developments of a high civilisation, their influence is still not entirely effaced. The principle of substitution was familiar to all the nations of antiquity, to the Israelites not the least. Witness the universal resort to sacrifices, the theory of which is well indicated by that of Isaac in Genesis xxii. Further illustrative examples are afforded by the law of the scapegoat, in Leviticus xvi.; by the offering of children to Molech (Lev. xx. 2); and by the legend of Jephthah's daughter (Judg. xi.). With this, various ceremonies, involving either mutilation or the shedding of blood, were in vogue--for example, the priests of Baal (1 Kings xviii. 28); even cutting off the hair seems to have been in the nature of a representative sacrifice.[5] Hence many German authorities cited in Keil's _Biblical Archæology_ (vol. i. p. 415) consider circumcision as a relic of ancient sacrifice: the consecration of a part of the body for the whole. The different grades in the process of humanisation may be assumed to have been successively attained as follows. In the earliest periods, human sacrifice was probably universal; in the Bible, we have the episode of Jephthah's daughter, above referred to; and in the narrative of Abraham's purpose to offer Isaac there is not the slightest indication of surprise on the part of the patriarch when he received Jahve's commands; whence may be argued evident acquaintance with such deeds. Besides which, we hear of human sacrifice among the tribes contiguous to the Israelites, until a much later date. Even the Greeks and Romans occasionally resorted to this during the historical period; in the Homeric age, it appears to have been a not infrequent practice. As, however, men progressed in culture and in humanity, such barbarity became impossible. Instead of putting their firstborn children (often by cruel methods, as in the sacrifices to Molech) to death, they propitiated the deity by an offer of the most precious member. Indeed, in the Genesis account of Abraham's circumcision, Mr. Moncure Conway considers (_Demonology and Devil Lore_, ii. 83) that the legend, subsequently obscured by later traditions, originally points to the performance of a much more severe operation. And when still more advanced, even this became impossible; the excision of a very small portion of the organ, not of indispensable necessity to the fulfilment of its functions, being substituted. After many generations had then passed over, the custom had become so firmly implanted in the mind and habits of the people, that its eradication was rendered a matter of extreme difficulty; even by new religious dispensations and more elevated modes of thought. Hence we find the rite among the Israelites made an exception to the fierce denunciation of mutilations in general, uttered by Jahve or by his messengers; and hence also, we see it (though not prescribed in the Koran) an ordinary modern custom throughout the whole of Islam, as well as among the Christian Abyssinians. The practice of self-emasculation in honour of a divinity was a common feature in the worship of Chronos, of Cybele, and doubtless of many other among the earlier recipients of religious adoration; it is referred to (and not in terms of reprobation) at Matthew xix. 12. It has descended to modern times--witness the fanatical sects in Russia; and even persons of high intellectual calibre (as, for instance, Origen) have submitted to it. What men regarded as honourable and meritorious in themselves, they would be not unlikely to impose also on their children. The existence of such ascetic practices among partially civilised nations must not be lost sight of in the present connection; as helping us to comprehend the mental religious attitude of primæval man. There can be little question that here we find our correct explanation of the origin and wide prevalence of circumcision. We are, however, no longer permitted to regard this as a hygienic custom, but simply and solely as a relic of barbarism; dating from an immemorial antiquity, long anterior to the first historical records, and when man was little, if at all, removed from savagery. The venerable age of the prescriptive rite, as well as the various social and religious phases through which the peoples adopting it have since successively passed, have effectually spiritualised it and have shed around it a certain halo of sentimentalism; but should not be suffered to obscure the only rational conception of its primary significance. The sacrificial character of the act among the Israelites was indicated by a former custom of placing a pot of dust in the room where the ceremony was to take place; that, as we read in the third chapter of Genesis, being the allotted food of the serpent. The practice seems to have continued down to a recent period, but now to have fallen into disuse. We thus clearly see that, beside being the sign of the covenant with the tribal deity, there was also involved the idea of a propitiatory sacrifice to the awful evil demons. The most clear instance of circumcision as an act intended to conciliate an offended divinity, or malignant spirit, appears in the strange story of Zipporah at Exodus iv. 24; where the vicarious nature of the rite is also plainly set forth. There is no apparent reason for identifying the Lord ('Adonai'); who sought to slay Moses, with Jahve; from whom Moses had just parted upon excellent terms. And there can be little doubt that Samael, to whom the scapegoat was subsequently offered (Lev. xvi. 20), or some similar dread power of darkness, is here meant.[6] If the writer is not greatly in error, an impression prevails in some quarters that _Moses_ either instituted anew or effectually perpetuated the rite of circumcision among the Israelites; as a useful measure of sanitation. However deservedly high the reputation of the great Hebrew lawgiver as a sanitarian, he does not seem entitled to credit in this connection; and alludes but casually to the ceremony, as to an already well-established custom, among certain directions for the treatment of the parturient woman at Leviticus xxii. 3. There is plainly no question of hygiene here involved. Dr. Asher (_The Jewish Rite of Circumcision_) considers that CHASTITY was the main purpose aimed at in the Divine injunction to Abraham; but, for reasons subsequently adduced, such a theory will be seen to have no foundation in fact.[7] As the present is not an antiquarian treatise, only a very cursory historic or ethnic account of ritual circumcision is here inserted; many other curious and interesting particulars may be found in the authorities cited at the end of this volume, as well as in the copious German literature on the same subject. All that has been attempted in the preceding pages is to exhibit the custom in its original character; and (in so far as the pretensions advanced upon its behalf as a surgical procedure are concerned), divested of the traditional sanctity which is possibly largely answerable for some of the views promulgated by medical authors; whereby the general habit and practice of the medical profession become also of necessity deeply tinged.[8] FOOTNOTES: [1] An account of the operation (seemingly then not infrequently resorted to) performed at a much later date for the above purpose, is to be found in _Celsus_, lib. vii. cap. xxv. [2] According to Keating's _Cyclopædia of the Diseases of Children_, 1890, vol. iii., some of the rabbins now omit it; "in the teeth of a strong and growing popular prejudice." I am informed, however, by the Rev. S. Singer, to whom I am greatly indebted for a courteous reply to inquiry on the subject, that these congregations would not be regarded as orthodox; and that the innovation is unknown in the Old World. [3] In the _Lancet_ of April 20, 1889, is figured a curious circumcising Instrument used by the Malays, who perform the rite upon boys at the age of eight years; and also upon females, about 1/8th inch being nipped off the extremity of the clitoris. In the ceremony performed on female children, variations exist; other tribes remove the nymphæ. [4] _La Couvade_ was the designation of the unwritten law, according to which, directly an infant was brought into the world, the husband retired to bed and was sedulously nursed for a certain prescribed period; the mother, on the other hand, getting up and attending to the affairs of the household. Tylor speaks of it as "this once world-wide custom" (_Primitive Culture_, i. 76). [5] Examples of the substitution principle among various _modern_ races are to be found in Tylor's _Primitive Culture_, vol. ii. p. 36 _et seq._ [6] The imposition of circumcision by the Jews upon vanquished enemies, as the Idumeans and Itureans (Josephus, _Antiq._ B. 13) sounds the like note; there could hardly be any question of proselytism. At an earlier date these people would have been ruthlessly massacred _en masse_, like the Amalekites (1 Sam. xv. 8); slaughtered in great part, like the Moabites (2 Sam. viii.); or sacrificed, like Agag (1 Sam. xv. 3), to the deity of the conquerors. [7] According to the same writer, it is absolutely impossible to say, in any given case among the Mohammedans, whether circumcision has been performed or not; for, as the muco-cutaneous membrane has not been divided, 'the soft elastic skin of the penis easily comes forward and re-covers the glans.' He states that the performance of that particular portion of the ceremony which consists in tearing and removing the membrane in question, completely distinguishes the Jews from all the other nations of the world who practise the operation as a religious rite. [8] Two cases of interest in this connection may be here noticed. Dr. Levy, a Jew dentist of Stettin, states (_Medical Record_, May 3, 1890) that, like his father before him, he was born without a foreskin; further, that his four brothers, who died in childhood, were similarly circumstanced. The late Dr. Asher (_op. cit._), who must be considered a high authority in such a matter (so far at least as concerns his co-religionists), says: 'No part of the human body is subject to so many varieties and irregularities as the penis and foreskin.' He believes total absence of the prepuce to be extremely rare, and doubts whether such a phenomenon has ever occurred; but seems to regard a partial deficiency as nothing unusual. He states that in most, if not all, instances of supposed congenital absence of this structure, a small portion of the skin will be found prolonged to the glans across the intervening fossa; which morsel, however small, must be excised by the Mohel, with the usual formalities. A note informs us that, according to Jewish tradition, the following personages never had foreskins: Adam, Seth, Noah, Shem, Melchizedek, Jacob, Joseph, Job, Moses, Balaam, Samuel, David, Jeremiah, Zerubbabel. The second case bears upon the very heterodox theory of maternal impressions, and is reported in the same periodical, of dates Nov. 3, 1888, and March 23, 1889. It is that of a child born accurately circumcised, seven months and twenty days after the like operation on his elder brother (presumably in presence of the mother, although this is not stated). The local appearances in the two children are affirmed by Dr. Harvey, of Illinois, to have been exactly alike; 'the congenital case even showing the marks of the sutures.' Both of the above cases, together with Dr. Asher's experiences, may be respectfully commended to the notice of Professor Weismann. II NATURE OF CONGENITAL PHIMOSIS--PHYSIOLOGICAL IMPORTANCE OF THE PREPUCE. The word 'phimosis' ([Greek: phimoô], I bind) signifies that condition of the penis in which the prepuce cannot be retracted beyond the _corona glandis_; and which may be either congenital or factitious. The latter is a pathological phenomenon, the product of injury or of disease. To apply the term 'abnormal' to the former is, however, hardly permissible, except when the difficulties in retraction are permanent and extreme; when they cannot be overcome by judicious perseverance, and by careful manipulation in the early weeks of infant life. A certain amount of adhesion between the two contiguous surfaces of mucous membrane is almost constantly present at birth, as a continuation of the normal intra-uterine agglutination (Keating's _Cyclopædia of the Diseases of Children_, 1890, vol. iii.; article by Dr. De Forest Willard). The radical defect in congenital phimosis is thus the adhesion or imperfect separation of two muco-cutaneous surfaces, normally developed in close contact. As a rule, these are so slightly connected that a very slight degree of force is sufficient to part them; but in a considerable minority of instances the defect eventually becomes permanent; with the natural growth of the organ more difficulty is experienced in procuring retraction; and various disagreeable, or even dangerous, symptoms are prone then to make their appearance. The complaint, however, is simply one of degree. If the adhesions at the margin of the urethral meatus are so tight that they fail to be quickly separated by the stream of urine directed against them--the force of which necessarily varies in different infants--considerable impediment to micturition results; and, perhaps usefully, serves to direct early attention to the state of the parts. In rare cases, no opening at all into the urethra has been discoverable; and complete retention has necessarily ensued. Very often, however, nothing of this sort happens for several weeks, months, or even years; and the existence, or rather persistence, of the disability may not be noticed at all until adolescence of adult life. The majority of instances lie between these extremes; not seldom unpleasant symptoms begin to be observed when the boy is a few months old; but there is a wide range of variation. The penile and preputial layers of mucous or quasi-mucous membrane being firmly adherent, and growth of the glans penis proceeding apace, certain consequences necessarily follow. The prepuce being (in extreme cases) tightly fixed to the margins of the urethral orifice, the _meatus urinarius_ still retains the same calibre as when birth took place, and becomes far too small for the needs of the rapidly growing child. A difficulty in effectually voiding the bladder is experienced, and may eventually result in complete retention. The little patient tugs at the seat of unpleasant sensation; and this elongates the folds of skin at the extremity of the penis, normally somewhat redundant, and extremely distensile. The muscular force of the bladder being spent upon overcoming the obstruction at the narrow meatus, the urine trickles out feebly, and 'balloons' in the soft pouches beyond, which continuously retain a few drops. Hence great local irritation and excoriation. It is not warrantable, however, to speak of _contraction_ of the penile mucous membrane. No contraction takes place, except as a consequence of inflammatory attacks; and these, in the infant, are rarely sufficient to cause any material shrinking. The phenomenon is simply one of natural development under a rigid restraining envelope; and though eventually the aperture is found narrow enough, the 'contraction' is relative only. So also, in every male child there is more or less seeming redundancy of skin at the end of the penis;--for natural physiological reasons. The condition is apt, as first stated, to become factitiously enhanced under the pressure of urinary obstruction. But there is seldom or never a _real superfluity of integument_ in this locality _ab initio_; in excess of what the subsequent needs of the full-developed organism may be reasonably supposed to warrant. It is requisite to lay some stress on these two points, as tending materially to influence our conceptions of the practice condemned in this pamphlet. Although plainly not absolutely essential to the due increase in bulk of the penis, or to the subsequent performance of its functions, it is _prima facie_ obvious that the prepuce must be intended to subserve some useful purpose. That, according to Dr. Willard (Keating's _Cyclopædia_), 'is to protect the head of the organ, during the years when the penis is but a portion of the urinary apparatus; and later, by its friction over the sensitive corona, to enhance the ejaculatory orgasm.' The latter half of this statement may fairly be questioned, as the prepuce is completely retracted during coition; and so no friction over 'the corona' can well take place under ordinary conditions. The first part, however, is unimpugnable; and to it may be added some consideration of the protection afforded during the first efforts at functional use. Some measure of the degree in which the glans penis is shielded from external irritating agencies is afforded by the sensations of the adult for the first time deprived of this appendage; or in whom the latter is kept retracted for any length of time, contrary to preceding habit. Extreme discomfort, indeed considerable soreness and actual pain, are complained of; until tolerance becomes established, and until the delicate membrane has by exposure and friction become so hardened that the absence of its former covering is no longer noticed, a period occupying commonly several weeks.[9] In the case of young children, the unpleasant sensations involved must be relatively far greater; considering their physical helplessness and their more impressionable nervous system. According, moreover, to the authority previously cited, early removal of the prepuce is apt to be followed by _progressive sclerosis_, with attendant evils of _contracted meatus_, _balanitis_, &c. And, failing this, 'the exposure of the tender skin to the friction of the clothing, &c. tends to keep up a state of abnormal excitement during the early years of life.' It thus becomes apparent that, apart from any risks involved by operative procedures, ablation of the prepuce, whether in infant or in adult, is not a measure to be undertaken lightly, or without satisfactory evidence of positive necessity. FOOTNOTE: [9] The fact that many adults, of not too sensitive organisation, gradually acquire a habit of retaining the foreskin partially or even entirely retracted, is of course not lost sight of. But this in no way affects the question of its _sudden_ removal, or of the protection afforded by the structure in question to infants of tender years. III DANGERS AND RESULTS OF CONGENITAL PHIMOSIS--ACQUIRED PHIMOSIS. A perfectly healthy condition of the male generative organs is compatible only with perfect mobility of the prepuce over the gland which it envelopes. So, in the absence of this, we encounter a number of ill consequences, some local only; some affecting the well-being, and even the life, of the entire organism. The parts being extremely vascular, and in very intimate relation with the central nervous system; we very naturally find that congenital phimosis, interfering with the normal growth of the glans penis, is prone to develop various reflex neurotic disorders or diseases; of which some have been minutely described by Dr. Sayre.[10] Thus forms of _paralysis_ may ensue; either confined to a single group of muscles, and simulating club-foot, or of a more general character. _Epilepsy_, _reflex cough_, _convulsions_, _choreic movements of the limbs_, are extreme examples; but a milder instance of the same causes in operation shows itself in young infants, as _nocturnal restlessness with defective nutrition_. _Hip-joint disease_ and _spinal caries_ may be simulated, and the mal-assimilation of food may eventually produce such gross deformities as _bowing of the legs_. Chronic _priapism_ is a not uncommon occurrence. Obstruction to the free discharge of urine may produce symptoms of severe _vesical irritation_, occasionally supposed to indicate stone in the bladder. The straining efforts at micturition may cause _hernia_ or _prolapse of the rectum_; the _nocturnal incontinence_ of children is not unfrequently traceable to the same source. _Epistaxis_ has been described. Retention of urine in the folds of the elongated foreskin, together with the child's habit of pulling this, induce a condition of soreness which causes great smarting whenever micturition takes place, and induces the patient to defer that act as long as possible. Hence may in time result _dilatation of the bladder, cystic kidneys, and death_. Even _eczema_ of the abdominal wall has been thus produced; and has disappeared when the cause was removed, as in a case cited by Dr. Hayes Agnew (_Principles of Surgery_, 1881). When the patient is allowed to reach adult life with the disability unrelieved, he becomes subject to attacks of _balanitis_; and the parts may ulcerate or even slough. In a case seen by the writer, where at the time no symptoms of inflammation were present, the retained deposits of smegma had ulcerated through the prepuce at various points--projecting from this exactly like chalk-stones from the fingers of a gouty person. In a unique case cited by Erichsen, 'Dr. Wisham, of Fyzabad, removed no fewer than 426 calculi, varying in size from a pin's head to a small bean, from this situation, in the person of a native of India, sixty years of age, who came under treatment for what appeared to be a large tumour at the end of the penis, the true nature of which was not detected until, on removing it, the knife grated against the contained calculi.' The defect constitutes a serious impediment to impregnation; in the event of an acquired local disorder, its presence seriously hinders diagnosis, and altogether precludes appropriate treatment. It has been supposed, and not without plausibility, to predispose to _epithelioma_. A case is given by Mr. Oliver Pemberton; and others have been reported. There can be no question that, under such circumstances, the presence of malignant disease about the glans would much longer remain undetected than in a normal state of the parts; and that the prospects of cure by operative removal would be proportionately lessened. Only comparatively mild examples of phimosis, in which the adhesions produced little or no constriction, and did not at all interfere with urination, could thus have been suffered to pass unrelieved until the subjects were far past maturity. Phimosis, as an _acquired_ condition, is of frequent occurrence in an _acute_ form; as the result of inflammatory oedema of the prepuce in youths and adults. This, again, may be a consequence of simple balanitis, the result of want of cleanliness, combined with disordered general health and a catarrhal state of all the mucous membranes; in which event it usually yields to mild measures, such as the injection of warm fluids under the foreskin. In by far the greater number of instances it is produced by venereal infection; and imperatively needs prompt operation, usually in the guise of slitting up the structure on a director. In a _chronic_ form, slowly and gradually coming on, and very intractable to remedial measures, it is not seldom seen in old men of gouty habit; and of consequently unhealthy and irritable mucous membranes. The pathology and treatment of ACQUIRED phimosis do not fall within the scope of the present work, but it is necessary to point out that these are essentially different from those of the congenital; and that the latter needs consideration upon principles totally diverse. In the congenital we have to deal with tissues _perfectly healthy_, and with skin peculiarly elastic and distensile. In the factitious, all the parts are more or less altered by _disease_, acute or chronic; and as a sequel to the latter, or to repeated attacks of the former, _true contraction_ takes place; the prepuce often attaining a hard and gristly consistence, under which condition simple dilatation is difficult or impossible. The phenomenon is rarely, if ever, seen in association with congenital phimosis; barring gout or venereal taint in addition. NOTE.--The infrequency of _cancerous disease_ attacking the penis, renders it unsafe to dogmatise upon any supposed causal relationship between that malady and the presence or absence of the foreskin, and does not appear to warrant any stronger assertion on this point than that which is recorded on the previous page. FOOTNOTE: [10] _Orthopædic Surgery_, p. 14. See also Hilton, _Rest and Pain_, p. 276. IV CUTTING OPERATIONS FOR THE RELIEF OF CONGENITAL PHIMOSIS; THEIR SUPPOSED ADVANTAGES. From the preceding, the evils or dangers incurred by permitting a male child to reach adult life; or, in the event of pressing symptoms, to pass even a few weeks or months with this disability unrelieved; are sufficiently obvious. Although, as Dr. Willard (_op. cit._) states, the adhesions between prepuce and glans can nearly always be broken down with sufficient readiness during the first few weeks after birth, there can be little doubt that, without conspicuous necessity, the medical practitioner will seldom care to 'make the baby cry,' and thus draw down upon himself vigorous maternal reproaches. It seems, moreover, hardly judicious to encourage any tampering by nurses or midwives, probably more or less ignorant and unskilled. We may take it for granted, therefore, that nothing will usually be done until the child is several months old; when some more energetic treatment will be requisite to remedy the condition in question. In milder cases no notice will probably be taken of the abnormality for at least several years, and its presence may be detected only by accident; the adhesions in such are trivial, and do not interfere with normal growth; hence are, as a rule, easily overcome.[11] Although less severe measures have been from time to time brought forward and advocated, the operation of circumcision is, to all intents and purposes, the only procedure in general use for remedying congenital phimosis; and as the latter is very common, so also is the performance of this ancient sacrificial rite among that large majority of the population who are otherwise in no way committed to it. There is a simplicity and thoroughness about the little amputation which may perhaps commend it to the surgical mind; and there are unquestionably certain superficial advantages of a hygienic nature about the patient's subsequent condition; though it may be doubted whether these are by any means so considerable as has been made to appear. However this may be, it goes without saying that no other curative proceeding has so far met with any wide favour in the medical profession; and, if one may judge from their published opinions, the leading exponents of medical practice and opinion, in this country at least, are so pleased with circumcision and its results that they would willingly see the Mosaic Laws in this particular extended to the whole Christian population, whether affected by phimosis or not. Witness Mr. Jonathan Hutchinson: It is surely not needful to seek any recondite motive for the origin of the practice of circumcision. No one who has seen the superior cleanliness of a Hebrew penis can have avoided a very strong impression in favour of the removal of the foreskin. It constitutes a harbour for filth, and is a constant source of irritation. It conduces to masturbation, and adds to the difficulties of sexual continence. It increases the risk of syphilis in early life, and of cancer in the aged. I have never seen cancer of the penis in a Jew, and chancres are rare.--_Archives of Surgery._ Arguments by this distinguished surgeon, in favour of extension of the custom as a matter of ordinary routine to every male Gentile, are to be found in the _Medical Times and Gazette_, December 1, 1855; together with a reference to previous utterances in an identical sense. Erichsen (_Surgery_, Ninth Edition, 1888, vol. ii. p. 1188) says: Every child who has a congenital phimosis ought to be circumcised; and even those who, without having phimosis, have an abnormally long and lax prepuce, would be improved greatly in cleanliness, health, and morals by being subjected to the same operation. It would be well if the custom of Eastern nations, whether it be regarded as a religious rite or only as a time-honoured observance, were introduced amongst us. In Holmes's _System of Surgery_, 1883, we read: Circumcision is the operation required in children; and it is best adapted for adults also when the skin is redundant, and the margins of the preputial opening are thickened. Mr. W. H. Jacobson (_Operations of Surgery_, 1889) says: This operation is still not practised often enough, especially among poorer patients; amongst whom many practitioners still treat phimosis as a matter of but little importance. Some of the pretensions set forth above on behalf of circumcision will be subsequently referred to; but on the plea for a general extension of the rite to nations not impelled thereto by special Divine command, it may be remarked that several Jewish surgeons who have written upon the topic by no means regard this with an eye of favour; and have, in fact, gone even so far as to denounce in the strongest terms its compulsory performance among their co-religionists.[12] For their dislike, they advance what appear to be very adequate reasons; and, in such a matter they must have enjoyed a far wider special experience than any practitioner without the Hebrew pale. The following extract from Erichsen's _Science and Art of Surgery_ (Ninth Edition, 1888) may be regarded as a typical account of the ordinary surgical operation in vogue at the present day. The italics are the present writer's: Circumcision in boys or adults may be most conveniently performed in the following way. The surgeon restrains hæmorrhage during the operation by tying a tape tightly around the root of the penis, or by compressing the organ in Clover's circumcision tourniquet, a most useful instrument, which can be slackened or tightened at any time. He next draws the elongated prepuce slightly forwards, until the portion of it which corresponds to the back of the glans is brought just in front of that structure. He then seizes the projecting prepuce immediately in front of the glans with a pair of narrow-bladed polypus-forceps, which he gives to an assistant, who must hold them tightly; or he grasps it and protects the glans by means of a plate which I have had constructed for this purpose. With one sweep of the bistoury he cuts off all that portion of the integument which projects beyond the forceps, which are then taken away. It will now be found that he has removed only a circle of skin, but that the mucous membrane lining it still tightly embraces the glans; this he slits up, by introducing the point of a pair of scissors at the preputial orifice; and then, trimming off the angles of the flaps, he turns back the mucous membrane and attaches it to the edge of the cutaneous incision by a sufficient number of fine catgut sutures. Before introducing these, he will generally find it necessary _to ligature a small artery on each side of the penis, and one or two in the frænum_. The best dressing in children will be some simple ointment, such as boracic acid ointment, or the glans may be simply smeared with a little vaseline. After every act of micturition the parts should be well sponged with boracic acid lotion or Condy's fluid and water. In the adult, union by first intention may often be obtained by a dry dressing of iodoform-wool thickly covered with collodion, so as to protect it from the urine. This may be left unchanged for four or five days. _There is usually a good deal of swelling of the mucous membrane about the frænum, and some solid oedema usually remains for some weeks after the operation._ This gradually subsides, and a linear cicatrix remains, which causes the patient no inconvenience.... _The chief points to be attended to in the performance of this operation, and on which its after-success is most dependent, are_--1. That too much skin be not removed; 2. That the mucous membrane be slit up to the base of the glans; 3. That too much of it be not removed; 4. That all bleeding vessels be tied with catgut ligatures, which must be cut short; 5. That the mucous membrane be well turned back, so as to cover the gap left by the retracted skin; 6. That all sutures be of catgut, which will be absorbed, and thus save the pain of taking them out. The _modus operandi_ of different surgeons varies in particular details, usually of a slight and unimportant character. The pithy description contained in Maunders _Operative Surgery_ may be appropriately quoted: The extremity of the foreskin being seized with forceps is drawn well forwards; the whole prepuce is embraced with the blades of dressing-forceps, immediately anterior to the _glans penis_, and cut off in front of the latter instrument. As soon as the forceps are removed, the skin will become retracted, leaving the mucous membrane still about the glans; this is slit up longitudinally as far as the corona, when it may be turned back, and its edge will come into apposition with the circular wound in the skin. The operation is now complete; but in the adult it will be well to introduce a few interrupted sutures. The prepuce has sometimes been _slit up longitudinally on a director_. Although well suited to cases of adventitious phimosis in the adult, the method is in no way adapted to the congenital form, and has never found general favour with the medical profession. It has no advantages over circumcision; although retaining the prepuce, it still leaves the glans largely uncovered; and the sharp corners of the divided skin, unless trimmed and rounded off, produce a very unsightly after-appearance. In performing circumcision many surgeons hold the clamp or dressing forceps which protect the glans inclined obliquely downwards and forwards, so as to leave a portion of the prepuce in the neighbourhood of the frænum unremoved. As one of the main advantages claimed for the operation is the prevention of future infection by retention of morbid material in the preputial folds, such a practice would seem to indicate a lurking disbelief in the validity of this pretension. If it be reasonable and right to excise the structure on these grounds, and if that proceeding be attended by such salutary effects; it is only logical not to do things by halves, but to make the excision as complete as possible. Thus Liston made his section near the frænum, 'so as to retain the skin on the glans, which is of advantage.' The use of the _elastic ligature_, and of the _écraseurs_, both ordinary and galvanic, for the performance of circumcision, are cruel and fantastic modes of effecting that object, which hardly need any expression of condemnation; and which it is difficult to believe can ever have been seriously advocated. Keyes (_Diseases of the Urinary Organs_, 1888), after breaking up adhesions with an oiled probe, marks an aniline line around the foreskin, and amputates the skin, &c., in front of this mark; thus previously estimating the amount of tissue to be removed.[13] For operations involving the amputation of the whole, or nearly the whole prepuce, the following advantages are claimed:-- (_a_) Greatly enhanced local cleanliness throughout after-life. (_b_) Greater chastity; and the preclusion of immoral personal habits. (_c_) A smaller liability to venereal contagion in after-life. (_d_) A diminished proneness to eventual cancerous disease. In respect of the first of these it may be conceded that, among a people naturally of uncleanly habits, abstraction of the prepuce would at any rate prevent mischief resulting from compulsory retention of the smegma. Whether it would lead to more frequent ablutions is perhaps doubtful; as also whether the plea has any valid efficacy in regard of persons belonging to the better classes, or to nations not specially distinguished (like the Oriental) for their disregard of the most elementary laws of personal hygiene. With savage tribes or with such races as the Chinese (many of whom are said to be completely washed from head to foot on two occasions only--when they enter the world, and when they have quitted it), anything conducing to more complete bodily cleanliness in after-life is certainly worthy of consideration; and probably of approval, even when it necessitates a surgical operation. But to apply this reasoning to more civilised peoples seems hardly warrantable on the facts in view. Shaving the head, or plucking out the nails would materially conduce to subsequent freedom from dirt; but no one would seriously advocate either of these as habitual customs; and the practice under discussion in no way differs from them, so far as the principle involved is concerned. The second of the reasons above assigned is one which has probably great weight in determining the practice of many surgeons; and it has even been gravely contended by one of the Jewish communion that the Deity instituted the rite among the Israelites in order to promote their greater purity and continence.[14] This suggests the irrepressible commentary that, whatever the case in bygone years, the operation seems now to have wholly lost its salutary effects in the direction indicated, as Mr. Jonathan Hutchinson (_Medical Times and Gazette_, _loc. cit._) himself testifies. Doubtless anything which might tend to enhance the chastity of many modern nations would be well worthy of serious consideration; with a view to its universal adoption. Strange to say, however, certain of those medical men who have investigated the question with opportunities of special experience, largely base their opposition to the practice of ritual circumcision upon the ground that removal of the foreskin in early life leads to premature sexual excitement, and a corresponding disposition to onanism. (Levit, _Allg. Wiener med. Zeit._, November 17, 1874.) In the _Lancet_ of April 4, 1869, two cases materially bearing upon this point are reported. One is that of a Jew, aged thirty-five, suffering from 'spinal paralysis,' which he attributed to a habit of persistent masturbation in childhood or youth. And allusion is made to a younger brother of the same patient; who, as a consequence of the same, had acquired spermatorrhoea, Dr. Willard (Keating's _Cyclopædia_) says: I have failed to find any statistics proving that the circumcised masturbate less frequently, or are more virtuous than others; and the exposure of the tender skin to friction of clothing &c., tends to keep up a state of abnormal excitement during the early years of life. 'Where doctors differ, who shall decide?' And in face, therefore, of such directly contradictory opinions from professional witnesses, it is difficult to believe that ablation of the prepuce is of material avail, either in precluding masturbation, or in promoting the subsequent chastity of the adult individual. On the third of the reasons assigned for advocating circumcision--the prevention of venereal disease when manhood is attained--Mr. Jonathan Hutchinson, whose testimony cannot but receive considerable weight, remarks that chancres are rare in the Jew. The observation has not been controverted; but must be received with a certain amount of hesitancy, in consequence of an evident bias in favour of radical measures of operative treatment. It seems rather to need confirmation by surgeons of the Jewish race, practising especially among their co-religionists. The present writer has been unable to discover any evidence in support from such a quarter. The authority last cited points out that cicatricial tissue is of all others least resistent to infection; and in the writer's own confessedly few opportunities for research in this particular field the number of Jews who have displayed remote but unmistakable indications of previous syphilitic taint has not appeared small. It is not improbable that a Hunterian sore developed upon scar-tissue, or upon the hardened integument of a denuded glans, would be far more trivial in character, more transient, less productive of inconvenience, and less easily recognisable, than the same in a normal state of the parts; the after-effects being, of course, identical. Such primary lesions in a people notoriously rather negligent of their person would seldom come under the notice of the medical practitioner. So, failing further evidence, the provisional verdict upon this question must be the Scotch one, 'Not proven.' But even if the above assertion be accepted in respect of true syphilis, it assuredly fails to hold good with reference to other varieties of venereal disease. Thus Mr. Jonathan Hutchinson's oft-quoted statistics[15] (_Medical Times and Gazette_, December 1, 1885), in his own words, 'prove that, though in proportion of nearly a third to the other patients, they (Jews) furnish nearly half the cases of gonorrhoea.' The last-named motive for circumcision, although, in the passage quoted at the beginning of this section, it has been stamped with the approval of the same high authority, needs but transient allusion. It is _a priori_ probable that congenital phimosis prolonged into adult life renders the subject thereof somewhat more likely to develop local malignant disease than any one not so circumstanced; the resulting attacks of inflammation and of unhealthy ulceration, &c., may be naturally expected to lead to the growth of papillomata, as well as to maintain a chronic condition of lowered vitality. But the comparative rarity of epithelioma in this particular locality would deprive the allegation, even if this were positively established as an indisputable fact, of any weight as an argument for the removal of the prepuce. Moreover, it is obviously a reason not for the routine performance of circumcision, but for the relief of phimosis; by whatever means attempted or proposed. FOOTNOTES: [11] In Druitt's _Surgeon's Vade-Mecum_, 9th edition, p. 662, are the notes of a case of 'congenital phimosis of the tightest kind' in an adult of twenty-three. Circumcision was threatened; but the affection readily yielded to the injection of warm water daily. There are probably many similar. [12] Dr. Asher (_op. cit._) does not disapprove of circumcision, but his evidently strong religious bias, and the fact that his whole work is composed from an ecclesiastical point of view, with the express sanction and co-operation of ecclesiastical dignitaries, constitutes him a far from independent (negative) witness. [13] An immense variety of operative procedures for phimosis, or even of details in the performance of ordinary circumcision, might be quoted. _Quot homines, tot operationes._ Their multiplicity, and the very contradictory nature of the advantages claimed for each, strongly indicate that neither the results of slitting operations, nor those of entire or partial excision of the prepuce, are found uniformly satisfactory. Thus, in addition to the methods described in the text, it may be noted that Jobert de Lamballe and others divide the foreskin on both sides of the frænum without excision; Van Buren makes two cuts, one on the dorsum and one near the frænum, subsequently removing the two flaps; Dr. R. W. Taylor (_American Journal of Syphilis and Dermatology_, October, 1872) makes two _lateral_ incisions with scissors. While, as above stated, some surgeons prefer to hold the forceps which guard the glans obliquely, from above downwards and forwards, so as to leave a certain portion of the skin about the frænum; Mr. Howse (_Guy's Hospital Reports_) advocates the careful removal of the frænum, in order to prevent subsequent oedema. Simple incision on a director was formerly preferred by many, though for congenital phimosis it has now probably fallen into disuse. In contrast with the careful devices for retaining part of the prepuce, or for ensuring that too much be not cut away, Sir W. Fergusson and Professor Humphrey find it best to amputate the structure as radically as possible. On this point see cases by Mr. Reginald Harrison, referred to at page 39. [14] See the _Lancet_, December 12, 1874. Dr. Asher (_op. cit._) also takes the same view. [15] The following is Mr. Hutchinson's statistical table derived from his practice at the Out-patient department of the Metropolitan Hospital: +------------+-----------+--------+-------------------------+ | Cases |Gonorrhoea |Syphilis|Proportion of gonorrhoea | | | | | to syphilis | +------------+-----------+--------+-------------------------+ |Not Jews 272| 107 | 165 | 0·6 to 1 | |Jews 58| 47 | 11 | 4·3 " 1 | +------------+-----------+--------+-------------------------+ On these figures a plausible inference might perhaps be founded, that what the Jew saves in immunity from syphilis he, to a certain extent, loses in increased proclivity to gonorrhoea; certainly the least of the two evils. Mr. Hutchinson goes on to state that of 252 children under the age of five years, 27 out of 179 Christians exhibited symptoms of congenital syphilis in a well-marked form; while only 3 out of 73 Jews were thus affected, the proportion thus being 1 in 6 among the Christians, while only 1 in 24 among the Jews. Again, of 97 women (two-thirds being married), of whom 92 were Christians and 5 Jews, 61 of the former were syphilised; against a blank return among the latter. Upon the evidence of these statistics, Mr. Hutchinson advocates a general adoption of the rite of circumcision by Western nations! Upon his own showing, however, the benefit to be derived from such a sweeping innovation, supposing that this were practicable, is not so very large; for 11 syphilised Jews out of a total of 58 with venereal disease, is a tolerably respectable proportion. The inferences here drawn, moreover, do not appear to have been confirmed by careful statistical observation carried out by other medical practitioners; among whom those of Jewish birth should be able to give specially valuable testimony. The field of inquiry was comparatively small; statistics drawn from the out-patient department of a general hospital are, for obvious reasons, not always of the most reliable character; and the conclusions may be vitiated by the facts suggested in the text. Hence, although they refer to but one venereal malady, it is hardly possible to acquiesce in them implicitly, even in this limited respect; without some confirmation drawn from a much more extended field of research. V DISADVANTAGES AND DANGERS OF CIRCUMCISION. As a surgical operation, circumcision is commonly performed with so much impunity that many surgeons will probably not be disposed to admit the possibility of its being attended by any danger to life; and there can be no doubt that it is but seldom followed by a fatal result. Still, with any breach of surface whatever, there must be a chance of blood-poisoning and of the absorption of septic materials; and, in the case of a child liable to hæmophilia, it cannot be doubted that serious consequences might readily ensue. Thus, in the third century it was enacted by the rabbins (_Talmud, Treatise Jebamoth_, 646) that, after two deaths in the same family from this cause, the ceremony was to be omitted; and the prohibition has continued in force ever since. Maimonides inculcates the utmost caution in the performance of the rite, and insists that 'in case of doubtful sickness, a child must not be circumcised; since danger to life overrides the whole ceremonial law.' (_Maimonides on Circumcision_, ch. i.). At the present date it is always effected by an expert (Mohel), who is not infrequently a qualified medical man; and accidents are guarded against with jealous care.[16] The ancient plan, according to which the operator received in his mouth (previously filled with wine) the extremity of the lacerated member, is now wholly or in great part abolished among the Jewish community; it being found that both syphilis and tuberculosis were thus communicated to the infant.[17] The _Lancet_ of October 1, 1870, quotes from the _Wiener Med. Presse_ the particulars of two cases, reported by Dr. Schwartz, of boys circumcised at the usual period; who subsequently died from phlegmonous inflammation and sloughing of the part, one five and the other twenty-five days subsequently to the operation. In the same periodical for December 5, 1874, may be found allusion to the experience of Dr. Kohn, himself a Jew; who stated at a medical society in Vienna, that during a practice of thirty-five years he had known six deaths from this source (_Allg. Wiener Med. Zeit._ November 17, 1874). He himself had thus lost a child of his own. However such fatality may be attributed to the neglect of all hygienic rules among the poorer classes of Jews; it can hardly be doubted that, under even the most favourable conditions, septic poisoning or uncontrollable hæmorrhage _must_ occasionally happen, albeit extremely rare; and this whether the operation has been performed from ritual or from surgical motives. To the absence of such cases reported in medical literature, too much weight must not be attributed.[18] It is rather upon the minor consequences, immediate or subsequent, that those who object to the practice have founded their opposition; and of such there has been no lack, especially among medical men who have been themselves Jews, and who have thus necessarily enjoyed the fullest experience of its effects. Thus the _Lancet_ of December 5, 1874, mentions a pamphlet by Dr. Levit, demonstrating the evils of the custom. He speaks of the premature beginning of sexual excitement in boys deprived of their prepuce, and the disposition to onanism so common to Eastern nations; he regards circumcision as a criminal manipulation; and calls upon the medical profession to oppose the practice, even at the risk of losing favour at the hands of the Jewish families they attend. And his arguments are effectually sustained by Dr. Kohn. Dr. Schwartz, in recording the fatal cases above quoted, 'deprecates the custom with great warmth, and expresses the wish that it may be laid aside.' Mr. R. W. Parker (_British Medical Journal_, July 19, 1879) refers to a child (one of a family of bleeders) who, being circumcised, nearly bled to death. He also says: 'Diffuse cellulitis of the penis is not an uncommon complication after this operation in unhealthy, ill-fed, and badly-cared-for children.' Dr. Mastin, in _Gaillard's Medical Journal_, speaks of the great frequency with which he has been consulted by Jews for chronic urethral discharges, irritable urethra, and other affections of the genito-urinary organs. He describes 'the preternaturally small meatus which results from early removal of the prepuce by circumcision.' (_Medical Record_, December 10, 1885.) Elsewhere in the same periodical (_Medical Record_, vol. xxi.) we are informed that 95 per cent. of young male Jew adults have this contracted meatus. Shorn of its natural protective covering, the muco-cutaneous covering of the glans soon becomes true dermoid tissue. Mr. J. Hutchinson (_loc. cit._) speaks of 'every one who is acquainted with the effects of circumcision in rendering the delicate mucous membrane of the glans hard and skin-like.' Contact with the clothing, &c., necessarily induces a chronic inflammatory condition of the part, followed commonly by contraction and condensation. We cannot with impunity rashly interfere with any of Nature's dispositions, however seemingly insignificant. This hard skinlike condition of the integument upon the glans penis, with its concomitant of narrowed urethral aperture, may be regarded as the normal result of circumcision. In the hands of bungling operators, however, far worse consequences may follow. Thus J. Bell (_Manual of Operations in Surgery_, 1866) 'has known the glans penis included in the incision in _at least_ one instance.' (The italics are his own.) Mr. Reginald Harrison (_Diseases of Urinary Organs_, 3rd Edition, 1887) has treated two _varieties_ of urethral stricture after circumcision which have not turned out well; in two _cases_, the extremity of the glans penis, including the meatus, had been wounded in making the section of the prepuce; in a third, owing to 'oedema and difficulty of ascertaining where the glans was, amputation had been performed, and the end of the glans included.' The second variety of stricture was caused by the prepuce being divided too high up, or, what amounts to the same thing, being drawn down too much over the glans penis, before being included in the forceps for the purpose of making the necessary section. On bringing together the parts with sutures, the tension on them was so great as to cause ulceration, and to leave behind a broad cicatrix, capable of exercising a contractile pressure on the under surface of the urethra; sufficient to impede micturition and to cause other discomfort.'[19] Dr. Hyde (_Boston Medical and Surgical Journal_, June 26, 1890) has seen disastrous results from circumcision; and Dr. Willard (in Keating's _Cyclopædia of the Diseases of Children_) says that, after circumcision, hardening of the glans occurs; and the evils of contracted meatus, balanitis, &c. follow, as pointed out by Otis, Mastin and others. So far, therefore, as the remote consequences of circumcision are concerned, there is strong evidence that the operation is by no means an unmixed blessing to its recipient.[20] Turning to the more immediate effects and consequences, the italicised passages in Mr. Erichsen's elaborate description concur with the experience since cited of other writers, to show the need of considerable caution in the performance of this surgical procedure. Septic infection, hæmorrhage, and subsequent sloughing of the part have to be sedulously guarded against; and on the Continent, at least, the resources of modern antiseptic surgery have been specially invoked. Without careful ligature of the arteries, these may, we are told, give rise to troublesome and long unnoticed hæmorrhage when the patient is put back to bed. The examples above quoted, and the varying practice of different surgeons, show, moreover, that discrimination and judgment are essential as to the excision of either too much or too little of the foreskin; both of which events may be disadvantageous. Mr. W. H. Jacobson (_Operations of Surgery_, 1889) says that after circumcision 'an adult should lie in bed for forty-eight hours, and keep on the sofa for a week, alternate stitches being removed at intervals. If he insist on getting about too early, he must run the risk of the parts remaining _long oedematous and tender_. And for this reason, with hospital patients, who have to come backwards and forwards, _early and complete healing is not to be expected_. (The italics are the present writer's.) It may be reasonably assumed that no sane man, who possessed the advantages of a sound and entire prepuce, would willingly sacrifice it without just and sufficient cause being shown. And his natural repugnance to such a deprivation would probably be in no wise lessened by a perusal of the passage last cited. It would be without doubt in the highest degree edifying in the present connection, were the sensations of some educated adult of average sensitiveness, who had submitted to the operation, placed on record; together with a statement of the time which elapsed before perfect tolerance became established; and before the 'hard skinlike condition,' so much approved of by Mr. J. Hutchinson, and the other more or less enthusiastic advocates of circumcision, was satisfactorily attained. In the absence of such a delineation, however, we can only surmise the feelings of the patient; and conclude that, as with catheterisation, and other manipulations addressed to a delicate mucous membrane, they would in some instances be almost _nil_; but that in the man of highly sensitive organisation, they would amount to keen and long-protracted torture. Infants of tender years must of necessity be classed in the latter of these two categories; in their case, there are also certain circumstances which tend to enhance the barbarity of the procedure; and largely to aggravate the suffering involved. Thus an American operator (at the association meeting of genito-urinary surgeons, reported in the _Boston Med. and Surg. Journal_, June 26, 1890) speaks of the difficulty of keeping children's knees out of the way after removal of the prepuce, and of the consequent torture to them. Even after healing, contact with flannel napkins, and other clothing, must long be very painful. There can be little doubt what would be the verdict--could they only give it utterance--upon the immediate results of the operation in question; returned by these inarticulate (if far from mute) victims of hygienic orthodoxy.[21] FOOTNOTES: [16] The most scrupulous and minute precautions for obviating any danger to life are enjoined by the Talmud. The ceremony is not permitted to take place at all unless the child is in perfectly sound health; and that Mohel, whose conscience may convict him of having caused the death of an infant by his negligence, is forbidden ever to officiate again. [17] A case of tuberculosis thus contracted is reported in the _British Medical Journal_ of March 5, 1887; and twelve other instances are also mentioned in the same paragraph. [18] The writer has been unable to discover any mortality statistics of ritual circumcision, and apparently none exist. Dr. Asher (_op. cit._) makes a remark to the same effect. [19] In the same work its author states that an unnatural smallness of the urethra is a not infrequent cause of incontinence of urine in children. In some cases therefore ascribed to congenital phimosis, may not the incontinence be merely a concomitant, and not an effect, of the latter condition? [20] Dr. Keyes (_Diseases of Urinary Organs_, 1888) has been 'twice called upon to relieve by operation a phimosis resulting from a former operation.' [21] An objection to circumcision, of wholly sentimental character, yet not the less worthy of practical consideration, may, in addition to those set forth in the text, be here noted. The parents of any child, in whom the necessity of some remedial measure for congenital phimosis has become apparent, usually express considerable relief when told that it is not necessary to make the infant 'a little Jew.' VI ABSENCE OF NECESSITY FOR CIRCUMCISION IN CASES OF CONGENITAL PHIMOSIS--THE RATIONAL TREATMENT OF THE LATTER. From what has been already set forth, it is sufficiently evident that no male should be suffered to reach adult life with this congenital disability unrelieved; and that in the majority of instances radical treatment is requisite at a far earlier date. There can be no doubt that it is infinitely better for an infant to be subjected to circumcision, than to pass many months or years with the unpleasant or even dangerous symptoms previously detailed. The point now to be considered, therefore, is whether these symptoms can be obviated by any less heroic measure, and whether the suffering thus incurred is a matter of absolute necessity; whether, indeed, it is right and proper to subject the child to _mutilation_ for the benevolent purpose indicated. For by no less term can the procedure in question be characterised. It consists in the abstraction of a structure, not indeed of paramount importance to the organism, but obviously evolved by Nature for wise ends as a protective covering. Were there no necessity for its presence, it would not occur; and without overwhelming evidence that such mutilation is unavoidable and beneficial, it must be held ethically criminal thus to lay rough hands upon a perfectly normal organ. As indicated above, congenital phimosis may be said in some slight degree to occur in every new-born male child. Two layers of muco-cutaneous membrane are developed in close contact, and are commonly agglutinated in a measure; but it is only when the separation is very incomplete that any defect producing consequences of importance is found. There is no deformity or deficiency of parts; and, except as a consequence of long-continued inflammation, no contraction occurs. What is commonly spoken of as 'a contracted prepuce' simply signifies the natural growth of the glans under a rigid envelope, primarily of normal proportions. All, then, that is requisite to remedy this condition in the first instance, is the due separation of the two contiguous layers of muco-cutaneous membranes, which in the new-born may generally be effected with ease. As the infant grows, however, there is apt to supervene relative disparity of size; the tissues cannot be sufficiently expanded to allow of the ideal state of the organ--a prepuce movable freely and loosely upon its included glans--without some laceration. And, unless care be taken, the wounds in the parietal layer of muco-cutaneous membrane again quickly heal; the new cicatricial tissue undergoes, perhaps, a little real contraction; and matters remain as they were before. Hence, probably, the disfavour with which procedures, involving dilatation of the prepuce, seem to have been hitherto regarded by most surgeons.[22] Some amount of reunion between the two surfaces may also take place at the spots where the adhesions have been ruptured. The principle to be aimed at, however, is simply the separation of two contiguous and adherent layers of mucous or muco-cutaneous membrane. Few medical men are probably aware of the natural distensibility of the parts; of the ease with which (when the patient is rendered passive and unconscious by means of an anæsthetic) the glans can be brought completely into view, and the prepuce perfectly retracted behind the corona. All that is then necessary is, by the use of emollients and by daily retraction for a very brief period, to prevent reunion of adhesions or of fissures in the muco-cutaneous membrane; until a sufficient degree of dilatation has been secured to preclude all fear of any future difficulty. Certain precautions are, of course, necessary. The patient should be anæsthetised; the tissues involved are extremely sensitive, and the administration of ether (or of chloroform in the case of a young child), besides relaxing the parts, enables the measure to be carried out much more efficiently than would otherwise be the case. Although the necessary dilatation can usually be very speedily effected, it often takes some little time thoroughly to remove the adherent smegma, not seldom of gritty and calcareous consistence. This, besides being the longest, is the most painful part of the manipulation. The use of cocaine as a local anæsthetic for such a purpose, precluding the administration of ether or chloroform, is not to be recommended. The wide surface involved renders its influence incomplete; and it is of considerable advantage to have the patient, particularly when of tender years, oblivious to what is going on.[23] If the distension be too timidly effected, so that the foreskin can be retracted over the glans only with difficulty; an equal difficulty will be found in pulling it forwards again, and temporary paraphimosis may result. Under anæsthesia, however, this cannot but prove transient; but if free dilatation be procured in the first instance, there is not the least fear of its occurrence at all. On the other hand, care is requisite not to lacerate unnecessarily the delicate membrane; after which more or less inflammatory trouble supervenes, and the necessary daily retraction of the foreskin, to be subsequently insisted on, becomes difficult and painful. Should much oedema thus occur, it is best to discontinue for a few days the retraction, until the inflammation has subsided; substituting the daily injection with a syringe under the prepuce of warm carbolised oil, in such a manner that (the orifice being closed), the fluid is made to distend and 'balloon' that envelope as much as possible. The ideal dilatation-procedure is how to effect the maximum of dilatation with the minimum of laceration. In boys of seven or eight and upwards, it is often easy to stretch the parts sufficiently to allow of easy retraction and of free movement backwards and forwards without a single rent in the membrane, and without the loss of a single drop of blood. In younger children, however, this structure is necessarily much more delicate, and easily torn, especially if there be struggling. In the latter case complete anæsthesia, plenty of deliberation, and the use of not too large an instrument, are elements of importance. The following is the usual method of performing this manipulation--'operation' is much too grave a word: The only instrument needed is an ordinary dressing-forceps of average size in the case of an adult or boy of age above indicated; proportionately smaller with young infants, in whom, indeed, a probe will sometimes effect all that is requisite. The patient being well anæsthetised, the surgeon, taking the organ in his left hand, retracts as far as possible the foreskin. With his right he introduces the closed dressing-forceps as far as it will enter; making sure, of course, that he has not passed it into the meatus. He then widely expands the two limbs of the handle, holding these apart for a few seconds. Complete retraction of the foreskin behind the corona glandis is then usually at once easy; adherent spots being separated with the thumb-nail. Should there be any difficulty the tissue is gradually peeled off by manipulation with the fingers; and the collections of inspissated smegma scraped off with the nail or with an ear-scoop. Finally, the operator pulls the prepuce backwards and forwards two or three times, making sure that it is perfectly loose; anoints the glans well with vaseline, and leaves it covered by the foreskin as in the normal state. Subsequently, complete retraction is necessary on each of the first four or five days; after which it may be gradually intermitted, being subsequently resorted to only for purposes of cleanliness. The daily washing recommended by some American writers seems wholly unnecessary; and, as before remarked, the less tampering with these organs (except when absolutely unavoidable) the better. When free movement of the foreskin on the glans has been attained, together with healing of any excoriation or sore, there is no fear of subsequent contraction. Any seeming redundance of the prepuce is in no way detrimental; it should only serve to induce a more careful habit of cleanliness, and the habitual use of those ablutions to which every man naturally resorts upon attaining years of discretion. Dilatation thus effected can at the least do no harm, and cannot possibly place the subject in a worse position than he was previously;--which the examples in previous chapters show to be far from the case, with the operation of circumcision. If carried out as here indicated, it will be found thoroughly effectual; the reasons why it appears to have failed in some hands apparently being: (_a_) neglect of after-treatment, and of care to retract the prepuce daily throughout the first few days; (_b_) insufficient dilatation at the time, so that retraction has never been perfectly easy; (_c_) avoidable and unnecessary laceration of the muco-cutaneous structures, followed by inflammatory mischief.[24] The adoption of a special instrument for the above purpose has been advocated from time to time by several writers, who speak in glowing terms of the favourable results they have thus attained. A rather formidable-looking one, used by Nélaton, is depicted in the _Gazette des Hôpitaux_, 31, 1868; this has three blades at right angles to the stem, and is somewhat on the model of an ordinary urethral dilator. Several successful cases are described, with one of failure. In the latter, a youth of seventeen, incision had to be resorted to, as the prepuce could not be stretched sufficiently with the instrument; and in this there was doubtless true contraction, probably as a result of venereal infection. In the _Dublin Quarterly Journal_, No. xlviii. p. 482, Dr. Cruise, of Dublin, figures a somewhat analogous instrument with two blades, and speaks of numerous cases ('in which with due care the result has been perfect') in his own hands and in those of his friends. He, however, kept the foreskin subsequently retracted for twenty-four to forty-eight hours, a proceeding which entails upon the patient very considerable discomfort, and is unnecessary. Dr. Hayes Agnew (_Principles of Surgery_) figures a special 'phimosis-forceps,' which appears in no essential particular to differ from ordinary dressing-forceps; the only noticeable peculiarity being that the blades are a little longer than usual. Levis's dilatation-instrument, described in Keating's _Cyclopædia_, vol. iii. p. 643, is worked by screw-power, and is stated to be 'very effective;' it resembles an ordinary pair of dissecting-forceps, with a screw placed close to the handle, which effects separation of the two blades. This is, no doubt, satisfactory in its results, but seems to be unnecessarily severe for the purpose to which it is applied; in which very little force is usually needed, or, indeed, is desirable, for obvious reasons. Mr. R. W. Parker's dilatation-instrument has been referred to on the previous page; and there are doubtless many others. Dr. F. H. Stuart, of Brooklyn (_Medical Record_, December 4, 1886), in advocating a manipulation very similar to the one here described (he introduces first a probe to break down adhesions, then the dressing-forceps, turning the latter round); comes to the conclusion that 'the number of cases which really require circumcision is extremely small.' And it may be generally remarked that no one who has really tried the dilatation plan with due care and without prejudice, appears to have subsequently relinquished it; or to have been otherwise than highly satisfied with its effects, whatever the precise method adopted. Those surgeons who speak of having seen unsatisfactory results generally convey the idea that these have taken place in other hands; and have never, in any publication seen by the present writer, condescended to details.[25] To the case of boys past the early years of childhood, and still more to that of adults, the arguments in favour of the substitution of a simple dilatation-process for the unnecessarily severe operation of circumcision, apply with redoubled force. As in these no symptoms directing attention to the phimosis have previously existed for any length of time, it may be taken at once for granted that, however tight the so-called 'contraction' may seem on inspection, the condition is present in only a minor degree; that under an anæsthetic the adhesions will yield to very slight force, and satisfactory retraction, with subsequent free mobility, be procured without the slightest difficulty. With adults, moreover, the avoidance of any need for confinement to bed, of even to the house, is an important consideration. In such the tissues are necessarily more elastic and less fragile than in young infants; there is much less prospect of laceration, with consequent tenderness and swelling. An operation for the relief of congenital phimosis advocated by Mr. Furneaux Jordan (_British Medical Journal_, May 2, 1863) may be here alluded to. Mr. Jordan passes one blade of a small round-pointed scissors (Critchett's strabismus-scissors answer well) through the orifice; skin and mucous membrane are divided to the length of a quarter of an inch on one side, the same being repeated on the other. The prepuce is now retracted as far as possible; this exposes more lining membrane between the lips of the wound, and this again is divided by a second incision on each side. The operation is now complete, and the foreskin may easily be retracted. The incisions which were made in the long axis of the penis after retraction become linear in a vertical direction, and almost imperceptible in the circular folds of retracted foreskin. In the after-treatment the prepuce should be kept back, or frequently retracted. In children retraction once daily for a week or ten days, till the wounds have healed, is quite sufficient. The extent of the incisions should, of course, be a little less in children, a little greater in the adult. The present writer has seen this operation performed in one instance, and the after-results were in the highest degree satisfactory. As contrasted with circumcision, the procedure merits warm commendation; preserving the useful foreskin, and followed by a much more speedy recovery than may be expected from the former. For the lacerations which may result from forcible dilatation, small nicks with a pair of scissors are substituted. The only objection is that even this operation, trivial as it appears, is seldom necessary; and that sufficient distension of the foreskin may often be procured without any breach of surface whatever. Moreover, some confinement to bed or to the sofa is subsequently requisite; whereas, after the effects of the anæsthetic have passed off, the patient, young or old, whose foreskin has been dilated, can behave exactly as usual.[26] Mr. Jordan's operation is, however, a very useful corollary to the dilatation-method in the chronic phimosis (often associated with gout) of men in advanced life; when the parts are usually in a very gristly condition; and when, if it be found impossible to procure retraction by stretching, the contracted tissues may be advantageously nicked with scissors in the mode here indicated. FOOTNOTES: [22] For instance, Mr. Erichsen (_op. cit._) dismisses the measure with the cursory allusion of a brief paragraph; against the long and elaborate account, previously detailed, of circumcision; it is not mentioned at all in the earlier editions of his work. Ashby and Wright speak of it with great disfavour. Mr. Jacobson (_Operations of Surgery_, 1890) does not introduce it at all; possibly because hardly worthy to be dignified by the title 'operation.' [23] In adults, or in boys approaching manhood, gradual dilatation by the daily introduction of a sponge tent has been recommended. It might be resorted to in the case of an exceptionally timid and patient individual, but hardly for any other. [24] Mr. R. W. Parker (_Brit. Med. Journal_, July 19, 1879) recommends gradual dilatation with a special screw-forceps, which he has used in a considerable number of cases at the Children's Hospital, 'always with good results.' [25] In the paper above quoted, by Dr. Cruise, of Dublin (1868), that surgeon speaks of Dr. Hutton having used dressing-forceps for the cure of phimosis fifteen years previously. Very probably the adoption of that instrument for the same purpose would be found on inquiry to date back still further; and no pretension of originality can be here put forth for the advocacy of a simple common-sense practice, which must have been repeatedly resorted to by many practitioners of the past. [26] M. Faure has also described a somewhat analogous 'nicking' operation. VII SUMMARY. I. Circumcision as a sacrificial rite has been practised by very numerous races of diverse origin, and dates from an extremely remote antiquity; probably from the Stone Age, as suggested by the internal evidence of Biblical records. II. This fact, together with that of its application by many tribes to the persons of female children, deprives the religious ceremony of any title to the hygienic character and purpose, which have been frequently attributed to it. III. The surgical operation of circumcision, especially where infants are concerned, has therefore to be discussed solely on its own merits, wholly apart from any theory of Divine intentions, based upon theological considerations. It appears to be erroneous _in principle_. IV. It consists in a _mutilation_; in the removal of a perfectly normal structure, with which, for patent physiological reasons, every male child is endowed by nature. The morality of such a practice, without grave necessity, is open to question. V. Unless as the result of subsequent disease, no deformity, and indeed no actual abnormality, exist as factors productive of the condition designated 'Congenital Phimosis.' Almost every male child suffers at birth from some degree of the same phenomenon--the imperfect separation of two muco-cutaneous surfaces, developed in contiguity.[27] VI. Symptoms ascribed to a 'contracted prepuce' are due to natural growth of the glans penis, when this physiological separation is very incomplete, and when, therefore, a rigid constricting envelope prevents development. _No true contraction_ exists, except as the result of superadded inflammation; and is rarely of much importance, unless an element of contagion has been introduced. VII. The rational treatment of congenital phimosis primarily consists in the efficient execution of the process originally intended by nature, but imperfectly carried out. And, secondarily, in precautions to ensure the permanently free mobility of the prepuce upon the glans penis. VIII. Such complete separation of the two contiguous layers of membrane may almost invariably be effected by very simple means; and, with some slight attention to after-treatment, will permanently secure all that is desired, without risk and without even transient disability. IX. The treatment of congenital phimosis by dilatation is the common-sense remedy for this condition. It has been carried out by many practitioners with different instruments and variations of detail; and all who have thus attempted it with ordinary care (including the present writer) seem eminently satisfied with the results.[28] X. When diseased processes co-exist with congenital phimosis, the case must necessarily be treated on its own merits. Simple dilatation, even if practicable, is not always sufficient, but should be combined with incisions of as limited a nature as possible. Mr. Furneaux Jordan's operation is then useful. XI. In the event of disease, the operation of circumcision is not devoid of risk, and should be reserved as far as possible for extreme cases, in which removal of the whole prepuce is obviously a matter of necessity.[29] XII. In healthy children the operation seems to be rarely fatal in this country. Many cases of death directly traceable to circumcision have, however, been reported on the Continent. XIII. The immediate effects of circumcision, especially when performed on young infants, involve considerable and protracted suffering. XIV. The most conspicuous _remote_ result is that of an extremely contracted _meatus urinarius_, as the consequence of subsequent inflammatory processes, due to the exposure and continual friction of the unprotected glans. XV. The compulsory enforcement of local cleanliness procured by circumcision seems hardly a sufficient argument for the general adoption of the practice by peoples not utterly indifferent to all laws of hygiene; and has little weight even in individual cases. XVI. The superior chastity and purity of mind and body supposed to be procured for its recipients by ritual circumcision, lie open to very considerable question, in the face of abundant well-known facts. XVII. The advantage of circumcision in obviating future venereal contagion is restricted by its principal advocate to one form (albeit the most important) of such disease. Even in this limited field the facts adduced appear open to dispute, and greatly to need confirmation by independent observers. XVIII. In the hands of careless or inexperienced operators the surgical operation of circumcision has been followed by the most disastrous permanent consequences. XIX. In face of the facts here set forth, it is NOT advisable to apply the operation of circumcision, as a remedy for congenital phimosis, to Christian infants; much less to extend this, as a routine custom, to the whole male population. FOOTNOTES: [27] The word 'adhesion' in the previous pages is employed solely as a term of convenience, to denote this imperfect separation, and does not imply any analogy to inflammatory processes. [28] The writer first drew attention to the advantages of this method of treatment in the _British Medical Journal_, Nov. 15, 1874. Having instituted a tolerably extensive search through the medical literature of the preceding three or four decades, he is unable to find any account of a case in which the procedure failed to effect a permanent cure, unless there had existed previous disease. [29] A fatal case, after circumcision for gonorrhoeal inflammation, in a youth of 17, is reported in the _Lancet_, Feb. 25, 1882. Death took place on the eighth day apparently from septicæmic pneumonia. _BIBLIOGRAPHY._ PUBLISHED WORKS. I.--MEDICAL. Erichsen's _Surgery_, Ninth Edition; Holmes's _System of Surgery_, Third Edition; Maunder's _Operative Surgery_; Joseph Bell's _Manual of Surgical Operations_; Jacobson's _Operations of Surgery_; Reginald Harrison's _Diseases of Urinary Organs_, Third Edition; Keyes's _Diseases of Urinary Organs_; Keating's _Cyclopædia of the Diseases of Children_; Ashby and Wright's _Diseases of Children_; Jaffé's _Die rituelle Circumcision im Lichte der antiseptischen Chirurgie_; Asher's _The Jewish Rite of Circumcision_; Wunderbar's _Biblisch-Talmudische Medicin_; Gideon Bircher's _Die Beschneidung der Israeliten_; Dr. Hayes Agnew's _Principles of Surgery_; Sayre's _Orthopædic Surgery_; Hilton's _Rest and Pain_; _International Encyclopædia of Surgery_, 1886; _Guy's Hospital Reports_; _American Journal of Syphilis and Dermatology_, October 1872; Walsham's _Theory and Practice of Surgery_, &c. &c. II.--HISTORICAL AND MISCELLANEOUS. _The Testaments, Old and New_; _The Talmud_; _Maimonides on Circumcision_; Tylor's _Primitive Culture_; Moncure Conway's _Demonology and Devil Lore_; Keil's _Biblical Archæology_; Smith's _Dictionary of the Bible_; Calmet, _Dictionary of the Bible_, _Encyclopædia Americana_, _Encyclopædia Britannica_; Howard, _Royal Encyclopædia_; _Penny Cyclopædia_; _Chambers's Encyclopædia_; _Encyclopædia Metropolitana_; Winer's _Realwörth_; Brewster, _Edinburgh Encyclopædia_; _English Cyclopædia_; Wilkes's _Encyclopædia Londinensis_; _Globe Encyclopædia_, &c. PERIODICALS. _The Lancet_, _British Medical Journal_, _Medical Times and Gazette_, _Medical Record_, _Dublin Journal_, _Boston Medical and Surgical Journal_, _Chicago Medical Standard_, _Gazette des Hôpitaux_, _Allgemeine Wiener Med. Zeitung_, _Wiener Med. Presse_, &c. BY THE SAME AUTHOR. THE PALLIATIVE TREATMENT OF INCURABLE CANCER. (With Appendix on the Opium Pipe.) 2_s._ 6_d._ THE REAPPEARANCE OF CANCER AFTER OPERATION. 5_s._ 6_d._ THE GENERAL THEORY OF CANCER-FORMATION. 1_s._ CLINICAL NOTES ON CANCER. 3_s._ 6_d._ J. & A. CHURCHILL, New Burlington Street. 
49662	----	The Cure of Rupture BY Paraffin Injections BY CHARLES C. MILLER, M. D. _Comprising a description of a method of treatment destined to occupy an important place as a cure for rupture owing to the extreme simplicity of the technic and its advantages from an economic standpoint_ CHICAGO Oak Printing Co., 9 Wendell St. 1908 Copyright 1908 By Charles C. Miller FOREWORD. In taking up the description of the injection of paraffin for the cure of hernia a number of remarks of a prefatory nature are called for, as it is necessary to justify a treatment which has come in for a considerable censure from surgeons who have had no experience with the method and who have judged solely from a few mishaps which came to their attention and which in no way permit of an accurate estimate of the treatment. Paraffin injections have been in use only a few years. When first introduced their value for the closing of hernial openings was mentioned. At the time the factors which made injections valuable for such treatment were not appreciated. Paraffin was merely looked upon as an agent which might be used to plug a hernial opening and such plugging of a hernial opening is impracticable without histologic changes in the tissues to cause permanent closure of the hernial passage. The need which Paraffin fulfills in Hernia. Paraffin has a tendency to promote the formation of connective tissue and in hernial cases there is invariably a state of the parts which will be benefitted by the throwing out of connective tissue in the neighborhood of the deficiency which gives passage to the hernial contents. Besides this production of connective tissue, the occlusion of the hernial sac and glueing together of the walls of the hernial canal, the plugging and supportive action of a material like paraffin is likely to be in a measure useful as the paraffin does not lie in the tissues as a single mass, but it is traversed by trabeculae of connective tissue. OPERATION WITHOUT ANESTHESIA A GREAT ADVANTAGE. Injections of paraffin are accomplished with such ease without anesthesia that the mere fact that a hernia is curable without the taking of an anesthetic is an advantage on the part of the paraffin method which will be highly appreciated by a very large percentage of patients suffering from rupture. It is safe to say that for every patient suffering from rupture who is willing to submit to the cutting operation four or five patients will be met who are afraid to submit to such operation because a general anesthetic is to be taken. Applicable in the Physician's Office. Paraffin injections may be made in the physician's office and there is no condition produced which renders it difficult for the patient after injection to go to his home, if he must not travel more than a moderate distance. The reaction may be such as to make it advisable for the patient to remain quiet for a week or even two weeks, though this is exceptional, yet such avoidance of exertion is not looked upon in the same light by patients as two weeks strict confinement to bed. The probability of escaping confinement is a great incentive to a patient to submit to an injection, when he would refuse operation. Injections are not necessarily unphysiologic as the sufferer from a hernia has a physiologic deficiency which the paraffin accurately fills with normal connective tissue. The dangers of injection can be eliminated. The technic is not difficult even when all precautions are taken. There is less likelihood of suppuration following the injection treatment than following the cutting operation. The consequences of suppuration are less. If suppuration occur after the open operation failure is likely, not to mention the danger of peritonitis. Such is not the case following injection, and while consequences are less serious suppuration is avoided much more readily than following the open operation. Only the operator thoroughly acquainted with the manner of disposition of paraffin should attempt the injection of hernia. Simplicity. To the skilled operator the injection treatment is exceedingly simple and the injection method must always be far more simple than the open operation can ever become. A hernia can be injected without haste in from two to four minutes. An assistant is of no use. The open operation cannot be performed without the aid of several trained assistants, and without elaborate and expensive preparations, it is not feasable as anything but a hospital operation. Hospital surgeons may be expected to condemn the injection treatment of hernia, as it will open to thousands of the profession a field which has hitherto been monopolized by the surgeons with hospital facilities. Experimental injections before human injections. Before injecting a hernia the operator should be thoroughly <a acquainted with the manner of diffusion of paraffin in the tissues. This experience can be gained by the making of numerous injections into the carcass of a small animal and the subsequent careful dissection of the animal. A dead cat, dog, rabbit, or chicken may be used for experimental injections and many such injections should be made. Hyperinjection of a hernial canal should be religiously avoided. Should the operation fail and the patient suffer from the presence of the paraffin it can be removed by surgical means and at the same time the open operation performed. The presence of the paraffin will not interfere with the successful performance of the open operation nor will it complicate the operation so that the chances of a radical cure are not diminished from this method, nor is the patient liable to a slower convalescence. Vehement protests against the use of paraffin injections are to be expected from surgeons doing the open operation, and unbiased readers should not be misled by condemnatory remarks from inexperienced sources. PREPARATION OF THE SKIN. The hair over the pubes and the groin of the affected side should be cut rather close and then the parts scrubbed with a solution of green soap. A small amount of a forty per cent. solution of formaldehyde may be added to the soap solution as this agent is a very powerful antiseptic. Soap solution. Formaldehyde solution, one dram (40%). Green soap, four ounces. Dilute alcohol to make one pint. The dilute alcohol is made up of equal parts of ninety-five per cent alcohol and water. After the parts are thoroughly scrubbed with this solution the soap should be removed with moist compresses and then the parts mopped with a solution of seventy per cent alcohol. Finally the field of operation should be flooded with ether as this agent is an effective antiseptic and also acts as a solvent for any greasy matter not removed by the soap. PREPARATION OF THE HANDS OF THE OPERATOR. Antiseptics cannot be as freely used upon the hands of the operator as upon the skin of the patient as the repeated application of the stronger antiseptics cause a scaling of the epithelial cells and finally the development of an irritated state which prevents cleansing of the hands sufficiently to permit operating. It is well to scrub the hands with the soap solution and then to follow with the use of the seventy per cent alcohol. The alcohol solution is the least irritating of effective antiseptics and it is the solution in which needles and leather washers should be kept, so that they are at all times ready for use. THE SYRINGE. The sterilized paraffin syringe should not be handled until the hands have been scrubbed. The washers and needles, just before using, should be removed from the alcohol solution. It is unnecessary to wash the alcohol from the fingers, washers or needles, in fact, it is preferable to leave it upon them. Using an extra large syringe it is possible to operate upon several patients without resterilizing the syringe. This instrument may be soaked in the alcohol solution, the needle changed and the operator may continue until the syringe is empty. Even though one have a syringe capable of holding enough for several operations it is well to have a second at hand ready for use as the instruments sometimes break or spring a leak when least expected. Never use a syringe which leaks, as one cannot tell how much is going into the tissues and how much is escaping. Leaks invariably occur at the side of the needle base or at the point of juncture of the barrel of the instrument with its anterior portion. Paraffin in the solid state will seldom if ever escape along the side of the plunger within the barrel of the instrument when the all metal paraffin syringe is used and the all metal syringe is the only instrument which should be used for paraffin injections. The screw piston is preferable to the sliding piston under all circumstances as it gives the operator a better control over the injection. Injections are made with the paraffin compounds cold so that considerable pressure must be brought to bear to cause the harder mixtures to flow through a long needle. PREPARATION OF THE SYRINGE. The plunger should be removed from the syringe and the instrument in two parts should be thoroughly boiled before filling. It should be scrubbed with soap and water if dirty or corroded before it is dropped into the boiling water. After boiling for a half hour the barrel of the syringe which is closed anteriorly, except for the needle opening, is held up and the melted paraffin poured in until the instrument is quite full, then the plunger is fitted in and pressed down until it is possible to assemble the instrument ready for use. Needles should be boiled. Leather washers when not in use should be kept in solutions of alcohol. Preparations for operation, such as sterilizing syringe and needles should be done hours before operation. If the sterilized loaded syringe is placed in a sterile towel it may be kept for days and then before use to insure sterilization it should be soaked in a seventy per cent solution of alcohol. If a needle is attached to the syringe when it is thrown in the alcohol solution it will be found that the paraffin in the syringe will not be affected by the alcohol. The instrument may be used from the alcohol without even drying it. Before inserting the needle for the injection of the paraffin start its flow and observe that the paraffin is escaping from the needle in a perfectly smooth string. The same words as to preparation apply when the white vaseline is used. This agent should always be sterilized by heat before placing it in the syringe and when syringe and vaseline are sterile the exterior of the instrument may be re-sterilized at the time of using by alcohol soaking. Paraffin in the liquid state may be drawn from a large container directly into the syringe when the needle has been removed. The needle may then be screwed in place and the instrument held with the point of the needle directly upward and pressure made upon the piston until all air escapes and the liquid paraffin begins to flow. Then the instrument may be allowed to cool and its contents to consolidate. Material injected at room temperature. All these injections are made with the material in the syringe at room temperature. The syringe may be left filled for days and not heated at all when the injections are finally made. In mid-winter if the syringe has been kept in a cold room its temperature may be so low that it may be advisable to warm it somewhat, but at an average temperature of seventy degrees Fahrenheit the mixture first described should flow freely through an ordinary hypodermic needle. PREPARATION OF THE PARAFFIN. Some operators have said a good deal about the paraffin and the proper place to secure it. As nearly as can be learned the compounds used in this country are products of the Standard Oil Company. The paraffin used in the formulae of this book has an average melting point of 130. For reducing the melting point of the paraffin mix the paraffin with the white vaseline of the Chesborough company. If an agent is sold in a tin stamped white vaseline it should have the name on the tin of the Chesborough company as this is the only firm having the right to use this name. Petrolatum albi or white petrolatum is a few cents cheaper than the vaseline but the difference is of so small an amount that it is better to use the vaseline rather than packages which may vary more than the Chesborough product. FORMULA NUMBER ONE. White vaseline, one-half pound. Paraffin, one-half pound. Melt together. This should be sterilized by having the mixture stand in a covered container in a vessel of water which is also covered and the water should be kept boiling for a half hour. Containers for sterilized compounds. With the paraffin may be boiled a number of test tubes. These after boiling one-half hour may be lifted from the boiling water with forceps. As they will be quite hot if they are held with opening downward the water will drain from them and their own heat will evaporate the few drops in the interior and they will be left dry. Into each test tube sufficient paraffin may be poured to fill a syringe and then they should be plugged with sterile cotton or corks which have been boiled. The test tubes containing the paraffin mixture may then be put away and when taken out at a later time for filling the syringe the paraffin may be melted by heat and poured into the sterile syringe or the paraffin may be boiled by holding the test tube over a Bunsen burner, or other heater. When paraffin boils the temperature of the boiling mixture is higher than that of boiling water but the boiling causes dense black smoke to be given off and this is objectionable in a closed room. Repeated boiling of paraffin causes it to discolor but this does not occur when the vessel containing the paraffin is placed in a water bath and the water around the paraffin container boiled. No smoking of the paraffin occurs when it is heated in a water bath and this means of sterilization is the most satisfactory though the first time the paraffin is sterilized it should be kept in the boiling water for a half hour. A softer mixture of paraffin, which may be used when in fear of the effects of the injection of the harder mixture, is made as follows: FORMULA NUMBER TWO. Paraffin, two ounces. White vaseline, eight ounces. Melt together and sterilize. This second paraffin compound is advisable when the operator is anxious to secure a plugging action with a mixture which will always be fairly soft, and which is less likely to be absorbed than plain sterilized white vaseline. Vaseline. The third compound is the sterilized white vaseline. It is probable that this agent is frequently absorbed in a comparatively short time but it has the valuable property of diffusing freely through the tissues so that it produces a more extensive reaction and when it is used in connection with the harder mixtures the operator may be more certain of securing an occlusive inflammation of the sac of the hernia and the more extensive production of connective tissues so that the parts separated to make way for the passage of the hernial sac are more certainly bound together. None of these mixtures are hard. If a portion of the mixture first described is secured under the arm for a half hour or held in the mouth for that length of time and it is raised to body temperature it will be found that it is comparatively soft. It is not a liquid and it is not likely to be absorbed, yet it is not a hard waxy mass. The great danger of the untrained operator is to inject too much at one point and should the operator do this and get it in the canal it will make a lump at one point and press unnecessarily upon the tissues and in time will be displaced and will drag involved tissues with it, producing discomfort by the distortion. POSTURE OF PATIENT FOR INJECTION. The patient for injection should be placed upon the back. When the thigh is slightly flexed the wall of the abdomen is relaxed and should the external ring be not dilated by the protrusion of a large hernia the relaxation obtained by the flexing of the thigh and allowing the flexed leg to rest against the other will relax and dilate the external ring somewhat so that it may facilitate the free passage of the needle and it will also permit of the more free moving of the point of the needle in the loose cellular tissues as the needle is gradually withdrawn. Pelvis high and head low. If the head is dropped low and the pelvis is high, a position easily possible with some surgical chairs, the veins of the cord are depleted and the likelihood of opening or entering a vein is diminished. This posture should only be used where there is a well marked varicocele and the suction method of inserting the needle should always be used. When the veins are dilated the elevation and their depletion may prevent the operator making several efforts to pass the needle without striking them, a thing which is easily possible in the presence of a canal full of dilated vessels. Should there be a well marked varicocele the blunted needle should be used so that it will not be possible to cut a vein by the moving of the needle and at the same time the operator should move the point of the needle slowly from side to side as it is withdrawn. SKIN INFILTRATION TO PERMIT OF INSERTION OF LONG NEEDLE WITHOUT UNDUE PAIN. It may be well to infiltrate the skin slightly at the site of the puncturing of the skin with the larger needle. To do this a weak cocain or alypin solution should be used. This solution is made by the addition of the cocain or alypin tablets to one or two drams of boiled water. A tablet containing six tenths of a grain of alypin or cocain is sufficient for a dram solution. A few drops of this injected over the external ring will permit of the passage of the needle through the tough skin without pain. The pressing of the needle along the roof of the canal is not usually sufficiently painful to call for much complaint from the patient. If the patients are nervous a preliminary injection of a one per cent solution of cocain or alypin into the inguinal canal is not contraindicated. To accomplish this the larger needle should be screwed upon the infiltrating syringe and as the needle is pressed into the canal the solution is slowly forced in front of the needle point. If sufficient solution is thrown ahead of the needle the passage of the needle along the inguinal canal is entirely painless. The infiltration of skin or canal being complete the needle must be withdrawn and the syringe emptied and the plunger pressed down so that the empty syringe is attached to the needle through which the paraffin injection is to be made when the operator has assured himself that the needle has been passed as far as desired without traversing or puncturing a vein. THE EFFECT OF PARAFFIN COMPOUNDS UPON THE TISSUES. No matter what precautions are taken, paraffin deposited in the tissues causes an increased flow of blood to the parts. The reaction is in the nature of a distinct active hyperemic state and it is sufficient to cause the proliferation of connective tissue. Even if pure white vaseline alone is injected there will be such connective tissue proliferation and if the paraffin is deposited close along the peritoneal surfaces of the sac sufficient of a circulatory disturbance will be produced to result in the sticking together of the serous surfaces of the sac and such sticking together of the walls will mean an elimination of the patency of the sac, one of the essential features of a radical cure. The paraffin compound number one is of such consistency that it is unlikely to be absorbed and properly placed with discretion it will favor the retention of the hernia by acting as a plug. This plugging action is not likely to be successful if the paraffin is simply thrown in as a mass, as it will be displaced, and when displaced it will make undue traction upon parts with which it is intimately connected so that should the paraffin be thrown in in the form of an irregular mass closing only a small part of the canal and such displacement occur the patient may suffer considerable discomfort. The corking action of the paraffin is not to be disregarded, yet at the same time it must be remembered that the injection must be so diffused that the supporting mass has quite a universal support from all the tissues from the internal ring clear out to the external ring. It must also be remembered that the paraffin thrown into the tissues causes a thickening of the tissues and should the canal be filled with paraffin with the thickening which so rapidly develops the canal will be unduly crowded. If the canal is plugged up tightly and marked pressure is made upon the nerves of the cord at one point it is likely that discomfort will be produced which will last for some time. Object of operator. The object of the operator is to secure a diffusion of the injection through the loose cellular tissues by the directing of the needle in all directions as it is withdrawn. This diffusion is facilitated by the nature of the paraffin. It is not to be forgotten that the vaseline diffuses very readily and extensively and if the operator is fearful of overinjecting the parts it is best to use it in excess rather than the harder mixture. If the needle is simply withdrawn the paraffin is not thrown into the canal in a regular pencil-like plug but it lumps irregularly with small diverticula projecting from each irregular mass. The free moving of the needle point in all directions as the needle is withdrawn favors the diffusion and avoids the unsatisfactory lumping of the injection. THE IMMEDIATE AFTER EFFECTS OF THE PARAFFIN INJECTIONS. Within twelve hours after the operation the tissues are almost certain to become quite sensitive to pressure. The reaction may be followed by considerable pressure pain for a day or two. Should the patient not be comfortable while at rest, that is sitting about or lying down; then something should be given to relieve the pain. Codeine is the most satisfactory agent for preventing the patient from feeling pain during the most acute stage of the reaction. Codeine does not put the patient to sleep as does morphine, nor does codeine constipate or make the skin itch. Codeine is only about one-third or one-fourth as toxic as morphine and consequently it may be given in a proportionately larger dose. It may be given in tablet form or in solution by the mouth. The best way to administer it is in doses of one-half grain every hour while the patient is suffering actual pain. Tell the patient that it will relieve him of unpleasant symptoms during the reaction and that it is undesirable that he should suffer from the reaction. In this way the patient will be kept quite comfortable during the time that the reaction is sufficient to cause pain. It is impossible to tell whether the reaction will be such as to cause any pain or not. In case it does not develop no internal treatment is necessary. Other agents may be used to relieve pain, though none offer the advantages of codeine without disadvantages. It is not advisable to let these patients suffer from a severe reaction. It is better to meet the first indications of pain with the free administration of codeine. The patient should not know the nature of the drug, and as it produces none of the peculiar effects of morphine it is not really a drug at all dangerous from the habit forming standpoint. Local applications of heat or cold may be used if the reaction is well marked. THE PRECAUTION USED TO PREVENT THROWING OF PARAFFIN INTO THE CIRCULATION. In all cases precautions should be taken to avoid throwing of the paraffin mixture directly into the circulation. This is accomplished by passing the needle slowly into the tissues which are to be injected and while the needle is passing through the tissues it should have a strong vacuum suction upon it so that should it strike a vein the blood will immediately begin to flow into the needle. To illustrate how easily blood may be sucked from a vein a hypodermic with a glass barrel may be taken armed with a small needle. If the arm of a patient be allowed to hang down the veins will distend and the point of the needle may be slipped through the skin and into the vein. If the vein is punctured by the needle point the instant the piston of the syringe is drawn back a vacuum forms in the syringe and the blood will flow into the syringe. This same method is to be used in the passage of the larger paraffin needle or any paraffin needle only as the needle is passed along its course the suction should be constantly exerted. This constant suction is secured by simply attaching the half glass syringe to the needle and then as soon as the point of the needle is under the skin the piston is withdrawn and a vacuum formed. Then holding the piston of the syringe out, maintaining the vacuum, the needle is pushed slowly in as far as the operator desires to inject. Should blood begin to flow into the needle at any point the onward passage of the needle is stopped and is withdrawn and re-inserted in a somewhat different direction, particularly if during the withdrawal a point is found where the blood flows steadily into the syringe. If at no point blood flows into the syringe it is plain that no vessel of dangerous size has been punctured by the needle. The veins of the cord are found rather closely around the cord and the cord usually lies below and behind the sac so that should the operator aim to carry his needle point along rather high in the canal he will be least likely to encounter these vessels. It is not to be forgotten that the veins of the cord are particularly likely to be somewhat dilated in these cases of hernia and the operator is taking more or less of a hazard in neglecting the suction technic outlined. It is not safe to trust to the fact that the paraffin is injected in a solid state as is asserted by some operators. It is true that paraffin in a liquid state is more likely to flow into an opened vein than the paraffin in the solid state, yet it is possible to throw a very small amount of solid paraffin into a vein if no precaution is taken to prevent it, and while a very small mass thrown directly into a vein would be harmless in nearly all instances it might do considerable damage should it be so unfortunate as to lodge in certain vessels. FACTORS TO BE CONSIDERED IN DEALING WITH INGUINAL HERNIA. The inguinal canal gives passage to the spermatic cord. It is an oblique canal extending from a point one-half an inch above the center of Poupart's ligament to the spine of the pubes. The cord emerging from the external ring continues into the scrotum, and the most definite manner of finding the external ring is by picking up the cord in the scrotum and following it with the index finger until the point of the index finger is pressed into the canal, the scrotum being invaginated at the same time. In scrotal hernia when the patient is placed in the recumbent posture the contents of the hernial sac may be pressed into the abdomen and the finger following the receding hernial contents will slip into the opening of the external ring. OPERATOR MUST BE SURE HERNIA IS REDUCED. A hernia should always be completely reduced before any operation is attempted and the size and situation of the external ring definitely determined. The larger and the longer a hernia has been allowed to go unreduced the shorter the inguinal canal will be, as the inner margin of the internal ring is gradually forced toward the median line of the body, and in very large hernia the external ring is stretched somewhat outward so that an opening exists directly through the abdominal wall. This character of hernia is such that three fingers may easily be pressed directly into the hernial interval and as a rule so much of the abdominal contents have been outside the abdomen for so long that the hernia cannot be overcome without decidedly increasing abdominal pressure. These cases in which hernial contents can be pressed into the abdomen by force and which markedly increase the intra-abdominal pressure when reduced are unsuited for any operative treatment which does not include excision of a quantity of omentum. The average case. In the average case the examination of the external ring will not show a canal so greatly dilated and it may be taken for granted that it has not been shortened to a considerable extent by the giving of the internal margin of the internal ring toward the median line. Under these circumstances the operator may decide that he has a canal of from two to three inches in length and lying parallel to Poupart's ligament and slightly above this structure. The sac of the hernia usually lies above and in front of the cord. Running closely connected with the cord are the veins which go to make up the pampiniform plexus. These veins being close to the cord and the cord itself quite susceptible to pressure it is advisable to pass the needle along near the roof of the inguinal canal and to attain this end it is well to locate definitely the external ring and to have a distinct knowledge of the exact situation of the upper margin of the ring. Considerable cellular tissue is found in the inguinal canal so that in passing the needle through the canal should it meet with considerable resistance it has no doubt missed the canal and entered some of the more resistant tissues making up its walls. The cellular tissue in the canal is to receive the injection of the operator and it will be his object to facilitate the diffusion of the various materials injected so that an extensive formation of connective tissue will be promoted. The plug action of the injection is not alone to be considered for the operator is then likely to throw too much into the canal and with the development of the connective tissue the canal is unduly crowded. The ill consequences of hyperinjection should not be forgotten. It is the error to which the beginner is most liable. WHERE THE INJECTION SHOULD BE PLACED. Some operators have been content to insert a needle over the approximate site of the internal ring and then to force it downward until it lies as close to the internal ring as they can approximate and then to throw in a mass of paraffin sufficient to occlude the canal at this point. If the needle is inserted about half an inch above the middle of Poupart's ligament it will be over the site of the normal internal ring. After the needle passes through the subcutaneous fat it will be felt to strike the firm fibrinous layers of the external wall of the inguinal canal. After the needle has passed through this firm layer it will enter the loose cellular tissue in the neighborhood of the internal ring. If the injection is diffused over an area of an inch or an inch and a half in circumference the internal ring is likely to be plugged for the time by the injection. The larger Hernia. Should the hernia be large the injection should be made closer to the pubes, but injection at the internal ring is not sufficient, the canal should also be injected with a certain amount of the paraffin and vaseline. The canal may be injected by passing the needle directly through the outer wall of the inguinal canal, remembering its course about one-half inch above the line of Poupart's ligament. The most satisfactory plan of injecting where the operator can successfully follow the technic is to find the external ring and then insert the needle directly into the external ring close to its upper margin and to carry the needle along for at least two inches. The suction technic should be followed and the needle should be moved in all directions as it is withdrawn and the deposit diffused as much as possible. About the external ring itself and directly between the pillars of the external ring a certain amount of the injection should be placed. THE AMOUNT OF PARAFFIN TO BE INTRODUCED IN A GIVEN CASE. The tendency is to overinject a case. One must not forget that the tissues will probably thicken to twice the size of the mass injected. The operator must estimate as nearly as possible the size of the tract to be filled and then aim to throw in enough to about half fill it. The diffusion of the paraffin will usually safely hold the hernia when the patient rises from the table. Should the operator throw in mixtures one and two until the parts are fairly distended and the hernia be not held it is better to use only the plain sterile vaseline for a subsequent injection at the site of the internal ring. If a half dram of vaseline at this point does not hold the hernia a small amount of vaseline may then be thrown in the central portion of the canal. At first the vaseline injections should be used whenever in doubt as to the amount needed above a certain point. As the operator becomes acquainted with the needs of cases by experience the vaseline can be largely substituted by the paraffin mixture number one. TECHNIC TO BE USED IN INJECTING INGUINAL HERNIA. Have a syringe loaded with paraffin mixture number one and another loaded with sterile vaseline. See that the paraffin flows smoothly from the syringe without leaks. See also that the vaseline syringe is working smoothly. Have needles intended for injection of paraffin free from this agent. Place patient on back, thighs flexed slightly or straight if the external ring is easily accessible. Follow the spermatic cord and locate definitely the external ring. Attach empty syringe to needle. Pass needle point through skin. As soon as needle point is through skin exhaust syringe. That is draw piston out to form vacuum in syringe and obtain suction. Pass the needle slowly through external ring and along close to the roof of inguinal canal. When needle is in full length, if no vein has been struck and blood aspirated into the syringe, detach syringe and screw the paraffin syringe tightly to needle. Inject a few drops of paraffin by screwing down syringe. As paraffin is flowing move the point of the needle about in the loose cellular tissue and continuing the injection slowly withdraw the needle. Continue moving the point of the needle in all directions as the needle is withdrawn so that the paraffin will be diffused as much as possible. As the point of the needle emerges between the pillars of the external ring discontinue the injection. Test the effectiveness of the injection. Allow patient to stand on feet. If the hernia reappears have the patient lie down again and reinsert the needle as before described and inject sterile vaseline rather than the paraffin mixture. Not more than enough paraffin to half fill the canal should be injected. If such quantity does not hold hernia sterile vaseline should be used discreetly until hernia is held. The surgeon must estimate the approximate size of the inguinal canal by the size of the external ring. If a vein is struck the needle should be withdrawn and the syringe emptied of blood; then the needle should be reinserted, using the syringe for suction. If a vein is struck a second time it will be well to insert the needle through the abdominal wall at the site of the internal ring and if no vein is struck at this point an injection may be made. If this holds the hernia it may be well to make no injection of canal for two weeks. During the interval even if the hernia does not recur it will be well for patient to wear web bandage truss or a spica bandage with a pad pressure over the inguinal canal. At the end of two weeks inject canal moderately with paraffin or vaseline to promote formation of connective tissue. If the injection of the canal at the site of the internal ring does not hold the hernia, reduce the same and make a puncture with a small needle through the external wall of the canal just above the external ring. If no vein is struck inject moderately and see if such injection holds hernia. In such a case place pad of moderate size over the canal and put on firm spica and have the patient stay off of feet as much as possible for ten days or two weeks. In this case the permanence of the cure will depend upon the amount of connective tissue formed. Injection at Internal ring. To inject through the abdominal wall at the internal ring select a point midway between the anterior superior spine of the ilium and the pubes and one-half an inch above the line of Poupart's ligament. This represents the site of the internal ring. The needle should be pressed through the fibrinous wall of the canal at this point and should be directed towards the pubes. If the hernia is at all large remember that the canal is shortened and select a point one-half or three-quarters of an inch nearer the pubes as the site of the ring. When through the outer wall of the inguinal canal the needle point will have a considerable freedom in the loose cellular tissue and the injection should be diffused in a circle of an inch or an inch and a half in diameter. Before taking off the suction syringe after the passage of the needle sweep the point slowly in a circle to make sure that no vein has been opened or is likely to be opened as the needle is swept about. The hypodermic needle for injection. A hypodermic needle may be used for an internal ring injection or an injection through the anterior wall of the canal, but in moving it about the operator should watch carefully and not break such needle. If a needle breaks it will be at the shoulder formed by the point of attachment of the shaft of the needle with the butt. The advantage of the small hypodermic needle is that it may be passed with very little discomfort to the patient and it throws a finer string of paraffin and favors diffusion of the agent. A hypodermic needle is lacking in length to inject the canal when passed through the external ring along the canal. Should the surgeon attempt injection along the canal and find the patient too nervous or the technic too difficult the hypodermic may be used and an injection made through the anterior wall of the canal at the internal ring, at about the center of the canal and about one-half an inch from the external ring. The hypodermic needle injections are simple and should be accomplished even on a very nervous patient without troubling to infiltrate with cocain or alypin. BE DISCREET IF INJECTION IS PAINFUL. Should a patient complain that the injection is painful inject very discreetly or better check the injection there, move the point of the needle and again try slowly. If the cold injection causes pain try at another point. Put in a drop or two and should the patient still complain discontinue and put on a spica or truss for a few days. Observe the reaction and then if it is not severe inject again. Remember that several injections may be made upon a patient but hyperinjection, that is the injection of too much, will cause no little distress and that it is impossible to remove all the paraffin mixture or the vaseline without an open operation, if they are not absorbed. Needle punctures should be sealed with collodion. No other dressings are required. Begin codeine early and use freely when a painful reaction develops. THE INJECTION OF FEMORAL HERNIA. The femoral ring is below Poupart's ligament. When the femoral hernia protrudes through the crural canal it is directed upward over Poupart's ligament. To reduce it press the mass toward the feet of the patient and then upward toward the abdominal cavity. The saphenous opening may then be felt. On the outer side of the opening is the large vein of the thigh. The needle should be inserted at the inner extremity of the opening, that is toward the median line. Aspirating of blood may mean the puncture of this large vein and it may not be advisable to inject carelessly when this vein has been wounded owing to its size. The crural canal is only about a half inch in length. The injection of it may be accomplished with a hypodermic needle. It is not well to sweep the point of the needle externally with too great freedom as the vein may be wounded. Inject slowly and move the point of the syringe carefully so that the injection may be diffused in the canal. INJECTION OF UMBILICAL HERNIA. Reduce the hernia and examine the margins of the hernial ring with care so as to be thoroughly acquainted with the character and situation of these margins. Remember that the tissues are often very thin and that an injection in the center of the hernia may simply go through the peritoneum and thus be placed directly in the abdomen. Injections of paraffin into the peritoneal cavity of animals have not proven to be dangerous, the agent not causing irritation of the surface of the peritoneum when sterile. Umbilical hernia may be injected with a hypodermic needle building out from the margins of the hernial opening, but it is well not to inject with too great freedom. After diffusing the tissues of the canal or ring a pad and binder should be applied and the patient given two weeks interval to see if sufficient of the connective tissue has developed to close the canal. If the hernia is not overcome and recurs injections may be repeated. Case Reports Case 1. Case 1 A. G.--Italian child, age twenty-eight months, female. (Ass. Civ. Char. Disp.) Umbilical hernia protruding about one-half inch and with an opening which may be filled by tip of index finger. Parts thoroughly sterilized, hernia reduced and contents held in abdominal cavity by pressure of index finger of assistant. The margins of ring and the skin covering hernial opening injected with paraffin of melting point 108. In effort to avoid puncturing of hernial sac and throwing paraffin into the peritoneal cavity the skin of sac injected with the paraffin. About half dram amount used. Operation Jan. 17, 1905. Jan. 18, 1905. Temp. normal. Parts sensitive. Cries and struggles when parts touched. May 13, 1905. Last examination. Skin somewhat red. Paraffin mass easily palpable. Skin red but not sensitive. Case 2. Case 2 A. C. C.--Disp. W. P. Swedish boy, age 2 years and 9 months. Injected Feb. 3, 1905. Hernia as large as walnut. Reduced. Finger of assistant holding in contents. Injection made into tissue surrounding the hernial opening with view of crowding margins together. Half dram injected. Child crying forced contents into sac. Reduced and injection under skin of sac and around margins of opening to plug. Nearly dram paraffin used, melting point 108. Parts moderately sensitive at end of week. No redness though paraffin mass palpable close under skin and intimately connected with it. April 11, 1905. Last examination. No redness, no tenderness, no recurrence. Case 3. Case 3 T. F.--Teamster. Irish parentage. Age 20. A. C. C. Disp. Bubonocele, left side. First noted four weeks previously. Operation May 14, 1905. Area sterilized. Small area of skin infiltrated with a one percent solution of cocain. Paraffin melting point 108, injected over area of prominence of bubonocele and into upper portion of canal. Two punctures made a dram and a half of paraffin injected. Parts sensitive for three days so that patient walked without bending thigh at hip joint. No temperature. Local applications. Codeine given in quarter grain doses every two hours. Fourth day parts much less sensitive, can bend leg freely in sitting or walking. Area prominent from swelling but no impulse. Examination June 25, 1905. No pain, no tenderness, no impulse, prominence in region of internal ring slightly greater than on opposite side. Case 4. Case 4 A. P.--Sicilian. Worker in shoe factory. Age 24. Hernia four months duration. Never retained by truss. Sac extends half way to bottom of scrotum. Pubes shaved, skin sterilized. Operation Aug. 26, 1905. Skin infiltrated to allow passage of large needle without pain. Injection at internal ring of forty minims. Injections into canal of about thirty minims. In attempting to inject paraffin in cold state screw piston syringe broken. All metal syringe used for infiltrating, warmed and filled with melted paraffin. In using syringe to inject the canal near the external ring the needle plugged. Using all force possible the plug forced from needle and over a dram of melted paraffin thrown between the pillars of the external ring. Patient complained of considerable pain. Codeine used one-fourth grain every hour. On the third day after injection skin over the external ring infiltrated and with sharp spoon about a half dram of paraffin removed. Operation painless. Formaldehyde solutions one to five thousand used as moist dressings. Codeine continued for two days longer. Patient lost one week from work. Sept. 24, 1905. No recurrence, no pain or tenderness. Area at former site of hernia slightly more prominent than opposite side, no redness of skin. Case 5. Case 5 F. C.--American born, age 18. Private patient. Hernia about size of average marble midway between ensiform cartilage and umbilicus. Spontaneous origin. Injected at office with half dram of paraffin, melting point 115. Operation Dec. 2, 1905. About half dram total quantity used. No reaction when adhesive strip removed on fourth day. Slightly tender on pressure. Examination Feb. 7, 1906. No recurrence, no redness, no pain. Case 6. Case 6 J. C.--Italian barber. A. C. C. Disp. Inguinal hernia on right side. Noted three weeks before. Sac protruding through external ring. Injection after infiltration. Forty minims injected about internal ring. Twenty minims in canal. Twelve or fifteen minims thrown between the pillars of external ring. Codeine prescribed but not taken. Parts quite sensitive on third day. No fever. Sleeps well with two pillows under thigh of affected side. Fifth day, no pain, tenderness very much less, able to bend leg almost as freely as ever. Twelfth day impulse at internal ring? (Questionable.) Injection of twenty minims at internal ring, ten into canal and ten between pillars, melting point 104. March 4, 1906. Last examination. No recurrence, no pain or tenderness. Case 7. Case 7 A. Y.--Femoral hernia. Female, age 35, A. C. C. Disp. Worker in tailor shop. History of case indefinite as to length of time present. Never been treated in any way. Operation March 21, 1906. Injection of forty minims of paraffin through saphenous opening and about ten minims through Poupart's ligament. Codeine discontinued at end of fourth night. Tenderness slight. No recurrence at end of twenty days. Patient not seen subsequently. Case 8. Case 8 E. H.--Marshalltown, Iowa. Private patient. American born. Varicocele on left side and oblique inguinal hernia. Operation April 16, 1906. Infiltration and removal of dilated veins in scrotum. Wound closed and inguinal canal followed by large needle. No blood aspirated and cold paraffin mixture with melting point 115 injected along canal. About forty minims thrown along canal and then puncture made at site of internal ring and half dram diffused at this point. Personal communication one year later making final payment for operation. Patient cured and grateful. Case 9. Case 9--Italian section worker wearing spring truss for holding of inguinal hernia. Strong pressure of truss making marked depression at site of internal ring. Patient injected with dram and half of paraffin of melting point 115. May 20, 1906. Agent deposited along canal and at internal ring. One week later no pain, no tenderness to moderate pressure. Cord somewhat larger than normal and epididimus thickened but not tender. Shreds in urine. Through interpreter information gleaned that epididimus had been somewhat tender following operation. History of acute epididimitis some months before. Case 10. Case 10 A. J.--Patient first consulted at Harvey dispensary. Treated for urethral stricture by internal urethrotomy. Subsequently referred to A. C. C. Disp. for treatment. Developed acute appendicitis and operation for removal after development of abscess. Abscess drained and healing of abdominal incision imperfect leaving hernial protrusion internally and near superior angle of scar. Injected with seventy minims of paraffin, 115 melting point, on Aug. 2, 1906. No pain following injection, no discoloration, and no recurrence over a year and a half after operation. CONCLUSION. These cases represent the ten first which were seen subsequent to injection. Cases which were injected and which did not return subsequent to injection have not been included as they would be of no value in estimating as to the usefulness of this method. In no instance has an ill consequence been suffered which would cause the patient to seek surgical aid elsewhere, or at least no case has come to the knowledge of the author directly or indirectly. Large hernia which have gone unreduced for years have not been treated by injection and discretion demands that for some time, or until injection treatments have been practiced upon many patients, that large ruptures which have been outside the abdomen for long periods be left to the surgeon or be injected only by practitioners capable of doing the cutting operation in the advent of the failure of the injection treatment. The author for his own part has felt no hesitancy in injecting cases which promised a fair degree of success, realizing full well that untoward symptoms of a local character may be overcome by free dissection, removal of the paraffin and restoration of the inguinal canal by the usual surgical means. CONTENTS PAGE Foreword 3 Preparation of the skin 10 Preparation of the hands of the operator 12 Preparation of the syringe 15 Preparation of the paraffin 18 Posture of patient for injection 23 Skin infiltration to permit of insertion of long needle without undue pain 25 The effect of paraffin compounds upon the tissues 27 The immediate after effects of the paraffin injections 30 The precaution used to prevent throwing of paraffin into the circulation 32 Factors to be considered in dealing with inguinal hernia 35 Where the injection should be placed 39 The amount of paraffin to be introduced in a given case 42 Technic to be used in injecting inguinal hernia 44 The injection of femoral hernia 51 Injection of umbilical hernia 53 Case reports 69 Cosmetic Surgery The Correction of Featural Imperfections BY CHARLES C. MILLER, M. D. Very excellent and practical. _Southern Practitioner._ Will fill a distinct place in the realm of surgery. _Cleveland Medical Journal._ Covers a most important field of special surgery. _Southern Clinic._ The book is certainly a valuable contribution to the subject. _Ophthalmology._ Has gone far beyond the limits of surgery as understood and practiced in this country. _British Medical Journal._ The author has done the profession a service in offering his work upon the subject. _Yale Medical Journal._ The book furnishes in an extremely convenient and accessible form much information concerning a branch of surgery which is daily growing in importance and interest. _Military Surgeon._ Dr. Miller has made out a good case as to why the regular surgeon should give this question some considerable attention rather than leave such things to the charlatan and quack. _Canadian Journal of Medicine and Surgery._ 160 Pages. 98 Illustrations. Price $1.50. Transcriber's Notes: Words and phrases in italics are surrounded by underscores, _like this_. Spelling changes: acqainted to acquainted, ... thoroughly acquainted with ... patrolatum to petrolatum, ... white petrolatum is a few cents ... PRACAUTION to PRECAUTION, ... THE PRECAUTION USED TO PREVENT ... pertoneal to peritoneal, ... into the peritoneal cavity ... urtehrotomy to urethrotomy, ... by internal urethrotomy ... protrusian to protrusion, ... leaving hernial protrusion,... Opthalmology to Ophthalmology, advertisement at end of book Added missing period at end of chapter, ... reaction is well marked. 
19933	----	[Transcriber's Note: Illustrations without captions are described in the accompanying text.] [Illustration: _+The Five Members of the Cluthe Rupture Institute+_ CHAS. CLUTHE Founder of the Cluthe Rupture Institute 41 Years' Experience CHAS. CLUTHE, Jr. 23 Years' Experience in the Institute FREDK. WM. CLUTHE 21 Years' Experience in the Institute HERMAN CLUTHE 19 Years' Experience in the Institute ALFRED CLUTHE 17 Years' Experience in the Institute ] CLUTHE'S ADVICE TO THE RUPTURED BY Chas. Cluthe & Sons CLUTHE RUPTURE INSTITUTE Bloomfield, New Jersey (A Suburb of New York City) COPYRIGHT 1912 BY CHAS. CLUTHE & SONS TABLE OF CONTENTS Page One of the World's Most Terrible Burdens 5 Our Forty Years of Experience 9 Rupture Always Brought On by Weakness 12 How to Overcome the Weakness Which Causes Rupture 16 How Your Rupture is Kept from Coming Out 20 The Care and Attention We Give You 23 Able to Work While Being Cured 30 Don't Let Yourself be Scared into Risking an Operation 32 Why Ordinary Trusses Do More Harm Than Good 34 Law Should Stop the Sale of Drug-Store Trusses 38 Physicians Advise Cluthe Truss Instead of Operation 44 Ruptured People Swindled Out of Thousands of Dollars 46 What We Have Done for Over 290,000 Others 50 Costs More to Do Without it Than to Get it 52 The Special Advice You Get in Connection with the Cluthe Truss 57 Forms and Conditions of Rupture 60 Let Us Send You a Cluthe Truss on 60 Days' Trial 65 See How Little it Costs to Get Relief 68 Don't Let Yourself Keep on Getting Worse 70 _+One of the World's Most Terrible Burdens+_ Why So Few People Know of Anything That Will Do Any Good In a good many ways, rupture is one of the world's most terrible burdens. It is almost as common as poor eyesight. And the cause of far more trouble, far greater suffering and worry. For, while it's easy enough to get glasses that will improve the _sight_, only a small proportion of the vast host of sufferers have ever been fortunate enough to find anything that would even keep _rupture_ from growing worse. And about all a doctor can do is to suggest an operation. Though there are plenty of good physicians, plenty who can conquer other ailments, there are mighty few who can do anything whatever for rupture. But that is no fault of the physicians. [Sidenote: Medical Treatment is Powerless] This affliction, like trouble with the eyes or teeth, falls entirely outside the physician's province; for medicines, the physician's chief means of cure, are utterly powerless either to relieve or overcome it. And, unfortunately, scarcely one sufferer in a hundred knows of anyone else to turn to, with the exception of the surgeon, after finding that physicians can give no relief. For the proper treatment of rupture has received little attention as a specialized profession. Scientific treatment of the eyes and of the teeth have both become special professions; you'll find good oculists and good dentists in nearly every town. But, in all America, the Members of the Cluthe Rupture Institute are probably the only men who have honestly and conscientiously taken up the scientific study and treatment of rupture as their exclusive profession. There have always been plenty of places where a ruptured man could go for a truss; surgical supply houses, truss manufacturers, truss dealers, drug-stores, etc. But at these places, though their intentions are good, the men who undertake to fit you have made no special study of rupture, and therefore can do little or nothing for you. And the trusses they give you, because not based on a scientific study of rupture, don't make proper provision for your requirements. Then many sufferers, in their search for relief, have been handicapped by wrong ideas about rupture. [Sidenote: Many Wrong Ideas About Rupture] There has grown up a general impression that rupture is something to be ashamed of. But a badly mistaken impression. For the plain fact is that rupture, if you don't let it go till complications set in, merely indicates a weakness of certain muscles, and is no more to be ashamed of than a weak stomach or deafness, or poor eye-sight. Such wrong ideas-- and the false modesty they have bred-- have made rupture a tabooed subject; one to be talked about in whispers, one to be discussed with blushes. This lack of frank discussion-- lack of light on the subject-- has kept people in the dark. So the majority of sufferers haven't known just what was needed; in seeking relief they have had to trust largely to luck. That is why rupture has heretofore been such a terrible handicap. [Sidenote: The Misery It Has Caused] It has ruined the health of hundreds of thousands, simply because they couldn't find anything that would do any good. Kept them from getting much enjoyment out of life, sapped their strength and vitality, left them more or less helpless, robbed them of the ability to provide for themselves and families. It has probably kept more people from doing their best work than any other one affliction. It has kept many from doing any kind of work whatever. It has cheated American workingmen-- all those who have been its victims-- out of vast sums of wages. For there's a big difference between what a badly ruptured man can do and earn, and the earnings of one who is sound and strong. Some employers won't even hire a man if they know he is ruptured-- afraid he'll have to be so careful of himself that he can't do a good day's work. Rupture has kept lots of business and professional men down-- By robbing them of part of their efficiency, it has robbed them of the chance to get farther along; robbed them of money they might have made. For no man can be at his best in any capacity if his rupture is bothering him-- the drain on the strength is too great. It has interfered with the pleasures of thousands. Deprived them of recreation, kept them from taking part in athletics, kept them from getting proper exercise because they have known of no way to escape the danger that lies in sudden movements. It has made the lives of many women a burden; made it hard for them to do their work or to enjoy social affairs; deprived many of them of the blessings of motherhood. It has seized upon countless children; filled their days with suffering, robbed them of childhood's happiness. [Sidenote: Not Hard To Get Rid Of] But in spite of all that, when taken in time, rupture is no longer a hard thing to get rid of. So easy to overcome that many ruptured people can now be cured while _working_. And those who can't be cured, can at least, unless in the last stages, keep their ruptures from giving any trouble. The main point about rupture is that it requires very different treatment than any other ailment humanity is heir to. _Medical_ treatment, as everybody knows, can accomplish nothing whatever. _Surgical_ treatment or operation, as later explained, is usually dangerous. There remains only one means of relief. That is _mechanical_ treatment. Now, hundreds of methods of mechanical treatment-- trusses, "appliances," etc.-- have at different times been devised. But most of them absolutely worthless. For to perfect a beneficial mechanical treatment requires, in addition to considerable mechanical ability, a thorough knowledge of rupture; something few have ever taken the pains to acquire. But here at the Cluthe Rupture Institute we have had over forty years of day-after-day experience-- and successful experience-- in the study and treatment of nothing but rupture. And this has given us a thorough knowledge of the needs of ruptured people. As with all the great discoveries which have done so much for suffering mankind, there were many weary years of disappointment before we finally perfected the simple mechanical treatment which has since brought complete recovery to thousands. And, as shown in the following chapters, this simple, inexpensive way to relieve and overcome rupture is within the reach of every sufferer. Moreover, as explained on page 65, every sufferer can easily prove its merits by trying it sixty days at our risk. _+Our Forty Years of Experience+_ Day After Day We Have Dealt With Every Form and Condition of Rupture Like his father and grandfather before him, Chas. Cluthe, founder of the Cluthe Rupture Institute, made his start in life in the Surgical Instrument business. Learned his trade in the old country-- over in Germany, where the world's finest surgical instruments are made. Learned the business under the old-fashioned German apprentice system; and got a mighty thorough training, as most men do over there. When still a young man he came to this country; and in course of time, he started up for himself. Now, nearly all surgical instrument houses-- in those days same as now-- make or sell trusses. And Chas. Cluthe soon saw the utter worthlessness of all the trusses then in existence. [Sidenote: He Saw The Need For Something Better] He saw what a multitude of people were ruptured. Saw the great need for something better than ordinary trusses or appliances, something better than operation. He decided that by supplying that need he could be far more useful than by manufacturing surgical instruments. And from that day to this-- now over forty-two years-- the scientific study and relief of rupture have been the one aim of his life. That led, later on, to the founding of the Cluthe Rupture Institute. And there are now five of us-- father and four sons. For as we sons grew up, we were trained in our father's work in the field of rupture; and have become Members of the Institute. We four sons have all had the benefit of our father's forty years of experience. And the youngest of us has now had seventeen years of individual experience. And here, day-after-day, we have dealt with rupture in all its forms and stages. Altogether, at this writing, we have treated, by mail and in person, over 290,000 cases. All kinds, from infants in their mothers' arms to men and women over sixty and seventy. Among them some of the worst cases on record. We have made impartial, fair-and-square tests of every known method of treatment. We have had experience with all kinds of medical applications, and all kinds of mechanical appliances. We have fitted belt and spring trusses in all their variations. We long ago found just why they all fail to hold or relieve rupture-- just why they usually cause the wearer untold torture. We have had the co-operation of some of this country's most noted physicians and surgeons. We have studied the effects and watched the results in hundreds of operations. We have found just why operations are frequently fatal. Why they are nearly always dangerous. And why the rupture frequently breaks out anew, after the operation apparently heals. Every remedial means in existence for the relief of rupture has been tried. [Sidenote: The Result Of Our Study] And the result of all this study and experimenting was the invention of the famous Cluthe Truss and Automatic Massager. Something so vastly different from everything else for rupture that it has received _eighteen separate patents_. Something far _more_ than just a _truss;_ something far _more_ than merely a device for holding the rupture in place. Yet the _simplest_ truss ever invented. * * * * * The Cluthe Automatic Massaging Truss is so utterly unlike anything else for rupture-- so much more than just a _truss_-- that sometimes we feel we should have adopted some other name. For the country is full of _worthless_ trusses; and so many people have tried truss after truss without being in any way benefited that they think that nothing called a truss can do any good. Although when people get an inferior article of some other kind-- like clothing or shoes-- they don't condemn everything similar. This fear of anything called a truss has kept lots of people from answering our advertisements; lots of people, because of disappointing experience with other trusses, won't even take the trouble to investigate; give themselves no chance to find out about the merits of the Cluthe Truss. We would like to have these people believe in us and have them believe in our truss; but, by being so suspicious, they lose far more than we; they lose the chance to get better, and probably the chance to get well. We sometimes speak of the Cluthe Truss as the Cluthe Automatic Massager; both names are necessary if we would do our truss full justice. But we have decided never to give up the word truss; in spite of the fact that its use makes it harder to get people to believe our advertisements. We don't want to fly under false colors. We don't want to do any of the things done by those who have _worthless_ trusses to sell; those who have cheap contraptions which they call "appliances," "methods," etc., in order to deceive ruptured people. If we were willing to call the Cluthe Truss by some other name, we would probably disarm much of the suspicion many people have against the word truss. But we don't want to adopt any subterfuges. And there are now so many people wearing Cluthe Automatic Massaging Trusses, or who have worn them until cured, that simply by one man recommending the Cluthe Truss to another the prejudice against the word truss is bound to be overcome in time. _+Rupture Always Brought On By Weakness+_ The word _Rupture_ is _wrong_; a relic of the days when no one understood the real nature of this affliction. In its true definition, the word means a _break_ or _tear_. And that is how this ailment got the name _Rupture_-- people used to think the muscles had broken or torn in two. But we have examined hundreds of ruptures under the searching X-rays. And we long ago found that rupture is _not_ a break or tear; something all physicians and surgeons now concede. The muscles at some point have simply lost their _strength_-- lost their _elasticity_-- like a piece of old rubber which has lost its "_stretch_." [Sidenote: The Cause Of The Weakness] Sometimes this weakening is due to general poor health; sometimes to lack of exercise; and sometimes the weakness is inherited. Now the bowels are always _pushing_ or _pressing_ more or less against the abdominal wall-- any one, whether ruptured or not, can plainly _feel_ that pressure when coughing or sneezing; while lifting or other exertion greatly _increases_ the pressure or strain. When in a healthy or sound condition, the abdominal wall is _elastic_; and when the bowels push against it, the muscles which form it simply _stretch_ until the strain on them is over. Just as when you pull at your cheek, the flesh falls back in position the instant you let go. [Sidenote: Why The Muscles Give Way Under Strain] But if the muscles of the abdomen are in a _weak_ condition, they can't _stand_ much strain-- can no longer _stretch_-- any quick movement is often enough to cause them to spread apart, forming an opening through which a part of the bowels _pushes out_ or _protrudes._ Now there is only one way to _overcome_ that weakened condition; only one way to get rid of rupture without undergoing the dangers of operation. As a first essential, proper artificial _support_ must be applied at the point of rupture. Comfortable mechanical support that can be depended upon to hold the bowels always in _place_. Just as a broken bone must be held in place, while healing, by a bandage or plaster cast. Dr. Birkett, of the famous Guy Hospital of London, and one of the world's most eminent medical and surgical authorities, says this: [Sidenote: What Dr. Birkett Says] "The expediency of judiciously pursuing the mechanical treatment of every variety of hernia (rupture) cannot be too strongly urged upon the laity by the profession. In both sexes it should be carefully conducted the moment that the slightest protrusion shows itself; whether the hernia occurs in infancy, youth, middle age or at later periods of life, if properly watched and judiciously supported, it usually gives but little trouble; in many cases it is even cured. But on the contrary, if it be neglected, increase in bulk and, sooner or later, diseased states of the rupture, often leading to the death of the individual, will almost infallibly occur." And there is only one thing in the world that can _give_ the mechanical support which Dr. Birkett and other famous physicians say is essential. That is the right kind of _truss_. Any system of treatment (except operation) which claims to relieve or cure rupture _without_ the use of a truss is simply a fraud. [Sidenote: Why You Need a Truss] The weak muscles at the rupture opening can't possibly get strong without the aid of a truss that will do what the muscles themselves are _too weak_ to do; a truss that will hold the bowels in place. But trusses which will do _that_ even _half_ the time are mighty _scarce_. Thousands of sufferers have tried truss after truss in _hopes_ they would finally get one that would do it; and to this day haven't found such a truss. All trusses and "appliances" _claim_ to hold you together. But ordinary trusses-- those with bands or belts or springs around the body, those with leg-straps, those sold by drug-stores and "Hernia Specialists"-- are absolutely _wrong_ in principle, construction and action. They are like trousers worn without suspenders or belt-- continually slipping-- you've got to keep adjusting and "hitching them up." The "harness" shifts or pulls the holding pads _away_ from the rupture opening. Thus your rupture is continually coming out-- Nature never gets the ghost of a chance to start any healing process. But even if such trusses _did_ hold the rupture in place, that _alone_ could never result in cure; couldn't even result in improvement. Because that alone does nothing whatever to _strengthen_ the weakened muscles, or to overcome the muscle _lifelessness_, the conditions which _cause_ rupture. No man ever made his _arm_ strong by not _using_ it. And if a truss does nothing _more_ than hold the rupture in _place_, the _muscles_ at the rupture opening are never _used_, get no _exercise_, so they grow constantly _weaker_ instead of _stronger_. We have had cases here at the Institute where, for lack of _activity_, the muscles around the rupture opening had withered almost completely away. And usually, in addition to lack of use, the deadening, benumbing pressure from a wrong truss was partly responsible for that withered or deadened condition of the muscles. We can do nothing in cases like that. Neither can an operation or anything else. It is entirely too late. Like a man whose _arm_ has been _broken_. While carried in a sling or plaster cast, the arm tends to lose its _strength_-- loses it through lack of use. And if, after the bone has knit, the arm is still carried in a sling, never used, its muscles would soon _atrophy_ or become _dead_, weaken and waste away until useless. A _doctor_ would insist that the arm be _used_ or _exercised_ as soon as the bone had knit, thus gradually restoring it to strength. Same way with rupture. It can be _cured_ or made _better_ only by _strengthening_ the weakened muscles, gently _exercising_ them, giving them support which takes the _strain_ off them while _helping_ them do their work until, gradually, they _regain_ their _full_ strength and _need_ no help. Yet we of the Cluthe Rupture Institute are the only people to-day who take that physiological fact into consideration. How to _apply_ our knowledge of that physiological fact, _how_ to exercise and thus strengthen the weak ruptured parts while at the same time _supporting_ and holding them in _place_ wasn't the easiest thing in the world to discover. However, the Cluthe Truss or Cluthe Automatic Massager provides a way. And is the _only_ thing ever invented that can both _hold_ the rupture and give Nature the necessary assistance in the process of _strengthening_ the weak parts. Just _how_ it assists Nature is explained in the next chapter. _+How to Overcome the Weakness Which Causes Rupture+_ A New Way, But Based on a Principle as Old as the Hills-- A Principle Recognized by all Doctors As everybody knows, you can make most any part of the body _strong_ simply by _exercising_ it. Exercise is a wonderful thing. Keep a child cooped up-- give it no place to play-- and it will probably grow up puny and sickly. While a boy on the farm-- with the big out-of-doors for a playground-- is usually a picture of health. Or take a blacksmith. He is constantly _using_ or _exercising_ his _arms_. So you'll find _them_ as hard as nails. While his _legs_-- because he doesn't _use_ them so much-- aren't likely to be nearly so well developed. A man in an office or store usually has soft, flabby, _weak_ muscles. But let that man take up some form of _exercise_, like tennis or base ball, and his muscles will soon be strong. It is a law of Nature that our minds and muscles grow by proper use, building themselves up to meet any demands made on them. That is why, after any sickness which leaves the body _weak_, doctors nearly always tell you to take plenty of _exercise_. Until recent years, the only way to develop strength was by _active_ exercise; movement of the muscles by their own force, as in walking, chopping wood or playing some game. But nowadays there is a _substitute_ for exercise. [Sidenote: Massage Is a Substitute For Exercise] Called _Massage_; a sort of _artificial_ exercise; a way to strengthen muscles _without using_ them. In simple language, massage consists in alternately expanding and contracting the muscles by applying a gentle force _externally_, instead of moving them by voluntary and _internal_ force. Now massage-- like ordinary exercise-- is so _strengthening_ that it will overcome almost any kind of _weakness_. So _invigorating_ and _beneficial_ that many well-known physicians say the day is coming when it will be an almost _universal_ method of _cure_ for every trouble in any way due to weakness. At the Vanderbilt Clinic in New York, many cases of weak _ankles_, weak _backs_, etc., have been cured by massage. Now Rupture, as shown in the last chapter, is _also_ a weakness. But massage, as given at hospitals, can't be used to advantage for rupture. Too _expensive_-- requires an _expert_. And could be given only when you are lying flat on your back in _bed_; therefore couldn't be given very _often_; and it would take years for only _occasional_ massaging to overcome rupture. Moreover, hospital or hand massage could be used only in combination with a truss that would keep the rupture from _coming out_. A protrusion every day or so, as happens with most trusses, would _undo_ all the beneficial effects of the massage. But the invention of the _Cluthe_ Truss-- the _only_ truss that can be _depended_ on to _prevent protrusion_-- makes hand or hospital massage unnecessary; it takes their place. It massages the weak ruptured parts as well as a skilled hand-massager could, as well as could be done at a hospital. And charges nothing for giving the massage-- there is no expense beyond the price of the truss. [Sidenote: This Strengthening Massage Given Automatically] It massages the weak ruptured parts entirely _automatically_ or _mechanically_. And does it in a wonderfully simple way; the massaging device-- so small it would go in a watch case-- is so simple that you'll wonder when you see it how it can produce such a strengthening effect. Keeps massaging the weak ruptured parts _all day long_-- all without a moment's attention from you, all without keeping you from your work, all without in any way interfering with your pleasure. And, at the same time, holds the rupture constantly and comfortably in place. Takes all _strain_ off the ruptured parts, _rests_ the weakened muscles while the _massage_ is _strengthening_ them; just as you must rest a strained _ankle_-- keep your _weight_ off it-- while it is healing. Keeps you from even _feeling_ a single one of the strains that are apt to do so much harm when _other_ trusses are worn. That is how this remarkable truss, while overcoming your weakness, rids _work_ of all its _dangers_. Takes away all risk of further weakening yourself or of making the rupture worse. [Sidenote: Rids Work of All Its Dangers] Instead, any work you do will actually help make your rupture _better_, actually have a _healing_ or _curative_ effect. Every movement you make-- in working, walking, exercising, even in breathing-- so acts on the Cluthe Truss as to help produce the strengthening massage. This massage is wonderfully _soothing_, like gently rubbing a bruised spot. And is so remarkably beneficial that in about one hundred and ninety-nine cases out of every two hundred, the rupture usually begins to get better almost the day a Cluthe Truss is put on. So remarkably beneficial that the Cluthe Truss has cured some of the worst cases of rupture on record-- cured many of them even after everything else, including operation, had done no good whatever. For this massage does for the weak ruptured parts exactly what _exercise_ does for the _arms_ or _legs_-- gradually gives _new_ strength-- in most cases soon makes the ruptured parts as strong and sound as a dollar. * * * * * This massage, in some ways, is like _Osteopathic_ treatment. Which, as a cure for certain ailments, is fast taking the place of _drugs_ and surgical _operations_. Most likely you've heard or read about some of the Osteopathic cures. Nearly everybody, nowadays, has. Maybe you know of Osteopathic cures right there in your own neighborhood. Some of the cures made in this way seem almost magical. And it is largely because _massage_ forms a big part of it that Osteopathic treatment does so much good, especially in many kinds of _weakness_. [Sidenote: _+Something Like Osteopathic Treatment+_] Like a weak back, or weak kidneys, or weak or worn out nerves, etc. And there's only one reason why Osteopathic physicians can't cure _rupture_ as easily as any _other_ weakness. Like _hospital_ massage, it can be given only when you are flat on your back; and, unless a Cluthe Truss is worn-- which takes the _place_ of Osteopathic Treatment and makes it unnecessary, just as it does the hospital massage-- there would be no way of preventing protrusion _between_ treatments. Moreover, Osteopathic treatment, like hospital massage, would be too _expensive_ for most people. Even if given only occasionally. For Osteopathic physicians charge $3.00 to $5.00 a treatment. But the _Cluthe Truss_ keeps giving the _massage_ part of Osteopathic treatment-- the _strengthening_ part of the treatment-- all day long; and all without any expense, except the small cost of the truss. _+How Your Rupture is Kept From Coming Out+_ And How the Cluthe Truss is Held in Position by Suction-- No Belt, Leg-straps or Springs Around the Body The Cluthe Truss is the only kind in existence which applies the support at the proper _angle_-- _upwards_ against the rupture opening; thus counteracting the internal _downward_ pressure of the abdominal organs, the natural tendency of the bowels to push out. And, unlike all others, it is _self_-adjusting, _self_-regulating. Automatically adjusts itself with every one of your movements when you in any way exert your strength. Sudden strains or movements, like coughing or sneezing, like in working or exercising-- strains which would cause _other_ trusses to slip or shift out of position-- simply cause an instant, _automatic increase_ in the comfortable _support_ a Cluthe Truss gives to your rupture. [Sidenote: Holding Power Automatically Increases To Meet Any Strain] Every strain of any kind is instantly and automatically counteracted. After fitting men here at the Institute, we have had them do everything we could think of, but they couldn't throw the Cluthe Holding Pads out of position, couldn't force the rupture out. The holding power of this truss instantly increased to meet every strain the men made. The Cluthe Automatic Holding Pads-- the pads which hold the rupture in place-- are free acting-- work on a ball-bearing, universal joint. Thus they are wonderfully sensitive to the slightest movement, instantly respond to each movement. No other truss in the world has this self-adjusting feature-- no other can hold a bad rupture, no other can keep the rupture from getting worse. Just as no other can overcome the weakness which causes rupture-- no other can give the strengthening massage which the Cluthe Truss gives-- no other can make the rupture better. We have so much confidence in the Cluthe Truss that we guarantee in writing-- as fully explained on page 66-- that it will at all times prevent protrusion. * * * * * Another thing about the Cluthe Truss. In cases of Double Rupture, this truss is of course equipped with Automatic Holding Pads on both sides. While in case of Single Rupture, the side not ruptured is protected against strains by a free-acting Protection Pad; this supports and strengthens the well side, prevents all danger of double rupture. Every man who has a double rupture originally had only a single rupture. Most other trusses fail to provide any _dependable_ protection for the well side in Single Rupture. * * * * * And now note that when you put on a Cluthe Truss, there's no belt, band or elastic around the waist, no springs, no legstraps, nothing that can pinch, squeeze or bind, nothing that can cut, chafe or in any way irritate the skin. [Sidenote: Holds Securely Without Unnecessary Pressure] It is the only truss without "harness" of any kind whatever. It is held on the body by free-acting _suction_ or _vacuum_ Pads. These Pads rest lightly and comfortably over the natural cushion of muscles forming the rump. And hold the truss securely in position on the body in much the same way suction holds a properly fitting set of false teeth so comfortably in place that they seem like natural teeth. Because free from "harness," there is nothing about the Cluthe Truss that can bulge the clothing. It can be worn under corsets; or worn under _tights_ without _showing_. Many acrobats wear Cluthe Trusses under their tights when performing. Yet the Cluthe Truss doesn't squeeze or hug, doesn't bind against the body at any point save where the Suction Pads rest and where the Holding Pads support the rupture. This makes it the most _comfortable_ truss ever invented. Many people have written us that it is as comfortable as their _clothing_. * * * * * Another feature. Every part of the Cluthe Truss is covered with vulcanized rubber or waterproof casing. No leather or cloth or similar material to heat up the skin and make it tender. Nothing that can absorb perspiration; nothing that can get sweaty, sticky or foul-smelling. And because waterproof, it can easily be washed; easily kept clean. [Sidenote: Wear It When Taking a Bath or Swim] It is about the only truss that is _all_ waterproof. Therefore about the only truss you can keep on while taking a bath or swim-- a time when you are in danger, if you have no truss on, of having the rupture thrown out by the bending and twisting you do. Other trusses which claim to be waterproof can't be depended upon to hold-- won't hold successfully when you are in the water or any other time. It takes more than waterproof quality alone to keep rupture from coming out. * * * * * Yet, with all its exclusive superiorities, the Cluthe Truss-- including the professional services of the members of the Cluthe Institute-- costs only a trifle more than the worthless trusses which do little or no good whatever. _+The Care And Attention We Give You+_ All Without Taking You a Single Step From Your Home or a Minute From Work or Business When you try a Cluthe Automatic Massaging Truss, you will find that you get vastly different treatment-- vastly better care and attention-- than when you go to a drug store or local truss dealer. For you will get from us-- in connection with the Cluthe Truss, and without extra charge-- the skilled care and attention of five men (the five members of the Cluthe Rupture Institute) who are pretty well known throughout America as being foremost in the field of rupture. And you will get our care and attention-- and our special advice on your case-- without putting yourself to half as much trouble as when you go to a drug store-- You will get it merely by sending us-- as explained farther on-- a little simple information. [Sidenote: Distance Makes No Difference] We can study and understand your case as well with you five to five thousand or more miles away as we could with you right before us; or just as well as the best physician could study and diagnose a case of typhoid or other sickness right at the bedside of the patient. Our system of attending to people by mail is so exact-- and our knowledge and skill so great-- that no matter how far away you are we can fit you correctly with a Cluthe Truss just as surely as a high class tailor could fit you with a suit of clothes after taking your measurements himself. [Illustration: _+THE CLUTHE RUPTURE INSTITUTE+_] Here we have on file-- in writing-- complete particulars concerning each of the 290,000 cases we have attended to. Every case is carefully indexed and ready for instant reference. Nothing is left to memory or guesswork-- nothing can be overlooked, nothing forgotten. Thus your case can be easily and accurately compared with hundreds of similar cases. You see we have made mail order fitting and mail order care and attention a science. That-- together with the superiority of the Cluthe Truss-- together with the knowledge and experience gained through attending to thousands of widely different cases-- gives us a tremendous advantage over your local druggist or any one else you could go to. For years our Institute was located in the heart of New York City-- within a short car ride of several million people. [Sidenote: Our Advantages Over The Drug Store] And there-- in the course of years-- among the thousands of people who came in person to be attended to at our Institute, we had in our care case after case of every kind and condition of rupture ever known. And all this time we were also attending by mail to cases of all kinds in all parts of the civilized world. No druggist-- no truss fitter in any drug store or surgical supply house-- no one else in all America-- ever had such a wonderful opportunity to learn all the peculiarities of rupture. Our experience has been so complete that in the last five years we haven't come across a single case-- either by mail or among those who came to the Institute-- which presented any peculiarities that we were not already familiar with. Yet-- because he has never seen a case like it before-- a case that would seem simple to us often completely baffles the best of truss fitters in drug stores, local truss concerns, surgical supply houses, etc. Now it is only in the largest drug stores, local truss establishments and surgical instrument houses-- perhaps in only five or six places in a city like New York or Chicago-- that a special or "expert" truss fitter of any kind is employed. So if a comparatively simple case puzzles these "expert" fitters, a man certainly can't expect much satisfaction at the small drug store, where whichever clerk that isn't busy-- at best someone with little or no knowledge at all of rupture-- will undertake to wait on you. During our long experience, for every person who came to our Institute we have probably attended to ten others by mail. And we have proved over and over-- year after year-- that we can give relief by mail to the man five or five thousand miles away just as well as to the man who came to our Institute. [Sidenote: Give Entire Time To Attending Cases By Mail] So now we have moved our Institute to Bloomfield, N.J.-- only ten miles from New York City-- a quiet suburb where we can give our entire time to attending to cases by mail. For we have found that the great majority of the victims of rupture can't afford to lay off from work or business long enough to undergo operation-- the only thing besides the Cluthe Truss which can be looked upon as a means of relief; we have found that most ruptured people can't spare the money required for an operation; and that many of them-- largely because they have been wearing, for years, perhaps, trusses which have been letting them get worse all the time-- are so weakened and run down in health that they stand little chance of recovering from the shock of an operation. These are the people who are most in need of our truss and most in need of our skilled care and attention. And here in Bloomfield we can do more good, give relief to more people by mail, than we could had we remained in New York. And here, day after day, we are attending by mail to people in New York City-- only ten miles away-- just as we are to sufferers in Maine, Georgia, Illinois, Kansas, California, etc. [Sidenote: Well-Known Business Men Order By Mail] Big business men in New York-- bankers, presidents of big corporations, noted lawyers and others-- men perhaps living in the same block with some noted physician or surgeon-- men who could send for their autos and in fifteen to thirty minutes be in any one of New York's best hospitals-- men who can afford the best medical and surgical care in the world-- are among those who have ordered Cluthe Trusses from us here in Bloomfield in exactly the same way-- by mail-- that a man out in Ohio or Oregon would. Now when men like these-- many of them acting on the advice of famous physicians-- are taking advantage of the care and attention we give by mail in connection with the Cluthe Truss, it is mighty good proof of our ability to attend to any kind of case by mail. [Sidenote: How We Study Your Case] The first thing we do, when a man writes for a Cluthe Truss, is to make a careful, scientific study of his case. We must understand your case thoroughly-- know all its peculiarities. And please bear in mind that your case will receive the personal attention of at least three members-- perhaps there will be a consultation of all five members-- of the Cluthe Rupture Institute. No order is ever put in the hands of a clerk or helper or other inexperienced person. In each case we give our complete professional service. Each case is treated _individually_. We take into consideration the kind of rupture-- the location of the rupture opening-- the size of the protrusion, the length of time ruptured, the cause of the rupture, whether or not an operation has been performed, etc., etc. You will find, on our information blank (one is enclosed with this book, or see duplicate questions on page 73) some simple, easily-answered questions concerning these points. And your answers to these questions, if your answers are correct, furnish us all the guidance we need as to the special requirements of your case. Just as a physician in writing a prescription is guided by the answers to his simple questions. That is how we determine the shape and size of the Automatic Holding Pad (in case of Double Rupture, each rupture is _individually_ treated, usually a different kind of pad for each side, for both sides are seldom the same). And that is how we determine the adjustment of the pads and all parts, the amount of support needed and the regulation of the holding pads to give the support, etc., etc. Then, after deciding all these points, we make for you a _special_ Cluthe Truss-- one exactly adapted to your individual case-- every part of it exactly what your condition requires. (Compare _that_ with the way drug stores and local truss dealers try to fit you with a ready-made "stock" truss.) We next take this specially made truss to our Gallery of Statues-- which consists of life-size and life-like models or dummy figures. [Sidenote: Our Life-Like Models] And here, no matter what your size or build, we have a dummy model corresponding to your living self in shape-- a form your clothes would fit just as they fit on you. When we see the measurements you give when ordering (they are all provided for in a simple way on our Information or Question blank) we know at once which one of our many models or forms to use. And on this form-- duplicating your size and build-- we fit your truss, as soon as it is made, just as if you yourself were right here in front of us. We can usually make up your truss, fit it, and have it ready to send within twenty-four to thirty-six hours after receiving your order. Every day we fit in this way scores of people we have never seen. And it's only in about one case out of several hundred that we fail to give perfect fit. While in such cases, usually only some slight adjustment is needed to make the fit perfect-- some simple adjustment which the patient himself can easily make. Our common-sense instructions fully provide for proper adjustment if any is necessary. Our ability to meet the exact requirements of your case-- our expert skill and care in fitting-- are things no one else can give you-- for no one else has had our forty years of professional experience-- no one else has learned _how_, as we have. The method we follow (which is exclusively our own), is the only method of fitting that can result in continuous and comfortable holding. And continuous and comfortable holding, combined with the soothing, strengthening and healing massage treatment which the Cluthe Truss automatically gives, is the only thing (save an operation-- which can't always do it)-- that can effect a permanent cure. _+How Day-After-Day Holding is Given by the Cluthe Automatic Pad+_ [Illustration] The above illustration represents the side view of the lower abdomen of a person of medium size. C, A and E is the natural line of the abdomen. D, B and F is the line when the abdomen is inflated by coughing, sneezing, or any exertion or strain. The black disc is the pad. When the wearer coughs or strains, pad end A is forced to position B, while the lower or retaining end of pad E is instantly forced inward to position F, thereby completely checking the descent of the rupture and effectively locking it in. Thus rupture is at all times retained with the least possible pressure of pad under normal conditions, yet the extra pressure needed is instantly and automatically given when any exertion or strain demands it. This automatic action of the Holding Pad also _massages_ the ruptured parts. This massage has a soothing, healing effect-- like gently rubbing your forehead when you have a headache-- or like rubbing a bruised spot-- and, gradually overcomes the weakness which _causes_ rupture-- gradually _strengthens_ the weak ruptured parts, just as exercise strengthens the muscles of the arms. _+Able to Work While Being Cured+_ For men with a living to make, work to do, business to attend to, families to provide for, the Cluthe Truss is nothing less than a godsend. And it means just as much to men who want to take part in athletic games, men who want active outdoor exercise. Some, in their letters to us, have called it a _life-saver_. For the Cluthe Truss rids work and exercise of every one of their dangers; rids them of every one of their injurious effects on rupture. You who read this-- by letting us send you a Cluthe Truss on sixty days' trial-- can easily prove all that; just as thousands of others have proved it. With this truss on there isn't the slightest risk of having your rupture forced out by sudden strains or movements. Just bear _that_ in mind-- you who have been compelled, because your truss has been doing no good, to drop everything perhaps two or three times a day or more and put your rupture back. This truss puts an end to all danger of further weakening yourself while working-- puts an end to all danger of making your rupture worse. Just keep _that_ in mind-- you who now scarcely dare do a thing-- scarcely even cough or laugh, for fear of bad effects on your rupture-- for fear your truss will yield and let the rupture escape. [Sidenote: What You Can Do With a Cluthe Truss On] And with a Cluthe Truss on, work, exercise or outdoor sports will never cause any discomfort. Don't overlook _that_-- you who have been putting up with old-fashioned trusses or "appliances" with their belts, bands, elastics, leg-straps and other torturing harness-- trusses which hurt so much every time you move that they almost drive you frantic. Instead of letting work injure you in any way, a Cluthe Truss (as previously explained) makes the work you do and the exercise you take actually help make your rupture _better_-- makes your work actually have a _healing_ or _curative_ effect. There is plenty of proof of that. Men doing _heavy_ work, and doing it every day-- men like farmers, blacksmiths, railway firemen, factory workers, miners, etc.-- are among those cured by this truss; cured while _working_ right along, cured while earning good incomes. Also men taking more or less violent exercise, like base-ball players, tennis players, horse-back and bicycle riders, etc. [Sidenote: A Few Of The Men Who Were Cured While Working] Some of them, while working, remember, cured in less than three months. A lot of them cured in from four to twelve months; among them men who had been ruptured as long as fifteen to thirty years. And took only a little while longer for some who had been ruptured as long as fifty years to be cured. You will find, at the back of this book, many letters in proof of this. * * * * * We have seen the Cluthe Truss do so much good for so many other people that we feel sure it can do wonders for you. So sure it will help you, just as it did them that-- as explained in a later chapter-- we are willing to let you test it on sixty days' trial, to prove just how much it can benefit you. _+Don't Let Yourself Be Scared Into Risking An Operation+_ Cluthe Truss Has Done Away with All Need For Operation, Except in Occasional Cases People _used_ to think that an operation was the only way to cure rupture-- thought they had to be cut open. Just as people _used_ to know no better than to undergo _bleeding,_ no matter in what way they were sick. Histories and biographies tell us it was the loss of blood from this barbarous bleeding which led to George Washington's death. But nowadays we never hear of bleeding. Just as fever patients are no longer denied ice water and ice applications. Though, not so many years ago, people were literally allowed to burn up with fever. [Sidenote: Thousands Have Died Under The Surgeon's Knife] Operation for rupture, for reasons stated below has never been much more than a life-or-death chance, even for those with a rugged constitution. Thousands of ruptured people have died under the surgeon's knife. Oftentimes a weak heart-- because of the ether-- makes it unsafe even to attempt operation. And it has always been a big expense which not one in a hundred could afford. Even though it had no dangers, the cost and the long lay-off from work or business make it useless for the majority of sufferers to think of an operation. The reasons operation is so risky for most people are these: The sufferer is seldom in condition for an operation, is run down, the vitality is low-- that is why the muscles over the intestines have weakened and spread. Another grave danger lies in the fact that a very large opening must be made-- many delicate tissues cut through-- before the surgeon can reach the weakened muscles which caused the rupture. Moreover, in a surgical operation, the relaxed muscles are tightened simply by shortening them-- by cutting out a piece. But nothing is done to strengthen these muscles. Nature is in no way assisted. The parts usually remain weak-- that is why, when a man leaves the hospital after an operation for rupture, he is usually told to wear a truss or support. And that is why, in about six out of every ten apparently successful operations, the rupture sooner or later breaks out anew. So we would never advise an operation, save as a last resort. As in strangulated hernia, where there is no hope except through heroic measures. Save in very rare cases, there is now no need whatever to undergo the dangers of an operation-- no need to risk the surgeon's knife. No need to incur the big expense of going to a hospital-- no need to lose any time from work or business-- no need to be in bed a single day. For since the invention of the Cluthe Truss or Cluthe Automatic Massager, the day of operation is over, save for an occasional case. The Cluthe Truss has probably effected more _permanent_ cures than all the operations ever performed. And is always _safe_, and almost invariably _beneficial_, whether or not it brings complete cure. (Cure is sometimes impossible, as told in another chapter.) _+Why Ordinary Trusses Do More Harm Than Good+_ The country is full of trusses which are nothing but more or less worthless makeshifts. Some with so little merit that they try to hide under other names. Like the junk handed out at drug-stores. Like the traps peddled by the quacks who pose as Hernia "Specialists." Trusses and appliances with belts, bands or springs around the waist, trusses with leg-straps, etc. Some of these trusses cost little more to make than a pair of good suspenders or garters. A little leather, a few pieces of elastic or web band, a cloth-covered pad with sawdust in it, is about all there is to them. So, like suspenders or garters, they absorb perspiration; that rots them so they soon give out. But their greatest weakness isn't in their cheap materials; it's in their unscientific construction, in the fact that they usually do more harm than good. [Sidenote: Your Suspenders Would Do As Much Good As Some Trusses] A rubber band around your waist would do as much good as some of these makeshift trusses and "appliances"; and not be so apt to do harm. Might just as well wear your suspenders or garters over your rupture as some of the trusses and devices with which this country is overrun. Some of these trusses would hold your rupture just about as well if you left them hanging in the closet instead of wearing them. During the many years The Cluthe Rupture Institute was located in New York City, we had daily evidence of the utter worthlessness of all such trusses. Every day, one after another of the victims of such appliances were coming to us for relief. When we examined these patients, we usually found that the rupture had pushed the pads aside and worked out above or below them. Sometimes we found that the pads had worked away from the rupture opening, worked down against the pelvic bone. And the ruptured parts had slipped out and were being squeezed between the pads and the bone. A condition apt to result in strangulation. Some of these patients came to us suffering intense torture from the terrific pressure of such trusses-- pressure perhaps ten times greater than needed-- and this cruel pressure is exerted from the wrong direction, in the wrong place. Perhaps merely a slight sneeze or cough is enough to push the pads out of position. And then the pressure of these pads forces the ruptured parts out, instead of holding them in. Sometimes the pads had slipped down so far on the pelvic bone-- or had been pulled down by the leg-straps-- that there was no support for the rupture whatever. And this constant pressure against the pelvic bone saps the vitality. Often causing sexual weakness and mental failing. For between this bone and the outer skin is the sensitive life-giving spermatic cord. [Sidenote: Ordinary Trusses May Bring On Other Ailments] Also, we have found in hundreds of cases that these belt and spring trusses press against the femoral artery so severely that heart disorders result. Causing dizziness, headaches, irritability, etc. Yet the patient seldom associates his truss with these troubles, seldom knows their cause. And constipation and stomach troubles are often brought on by these trusses. Gas on the stomach is a common result. These troubles can be remedied only by removing the cause-- only by discarding the harmful truss. The Cluthe Truss soon overcomes such complications. We have countless letters-- from people formerly suffering from such troubles brought on by wrong trusses-- telling how the Cluthe Truss has given them a new lease on life-- made them feel many years younger. Among patients who came to us wearing spring trusses, we have often found evidence of injury to the spine. For such trusses press against the spine-- the delicate center of the nervous system-- just as cruelly as they dig into the abdomen and the pelvic bone in front. And frequently, when patients came to us wearing belt trusses, we have found the tender skin all cut and bruised where the belt fits around the body. And nearly always the cruel leg-straps had made the wearer's legs raw and sore. The sufferer who wears a truss like these can scarcely have a moment's comfort. Thousands of belt and spring trusses have been thrown away by new patients at our Institute, after we had fitted them with Cluthe Trusses. And among all these discarded trusses we have never found one that could be properly adjusted-- the pressure couldn't be properly regulated. There is by far too much pressure at times when only slight pressure is needed. And, at times of strain, when more pressure is needed, there is no increase in pressure to meet that need. This unregulated pressure tends to _stretch_ the weakened muscles at the point of rupture-- distends and enlarges the opening. That is one reason why a rupture grows constantly worse when a leg-strap or spring truss is worn. Such trusses are a _crime_-- wearing them is simply slow suicide. We keep a record showing the history of every rupture we treat. This record shows that every severe rupture with which we have had to deal has grown into a serious case solely through the wear of some form of the belt or spring truss. Just judge of all this by your own experience. Probably, in spite of the trusses you've been wearing, your rupture has grown constantly worse instead of better. And then-- for the sake of comparison-- just read some of the letters you'll find at the back of this book; see the verdicts of people who have had experience with both the Cluthe Truss and with other kinds. _+Trusses Like These Are A Crime+_ [Illustration: Common Elastic, or Belt Truss (Single)] So-called "Appliances" are Usually Merely a Slight Adaptation of this Style of Truss-- Merely the Most Worthless Kinds of Trusses Masquerading under Misleading Names. The only way to give leverage to the pad is to tighten up the belt and the leg-straps. The tighter they are, the farther they pull the pad away from the rupture opening. The leg-straps pull the pad down on the pelvic bone, where its pressure squeezes the life-giving spermatic cord. Whenever the wearer coughs, sneezes or is under strain, the bowels leave their natural position, working out and in through the rupture opening (due to flexibility and stretching of straps), and the bowels when out are repeatedly pressed between the pelvic bone and the pad. The Cruel Spring Truss [Illustration] It is impossible to keep the spring truss in position. Due to the force of the springs around the waist, the pads dig against the pelvic bone with terrible pressure, sapping the vitality. The previous chapter shows how most ruptures grow constantly worse when trusses like these are worn. [Illustration] Dotted lines in lower illustration show Spring Truss coiled up before applied. Try to hold springs apart as when on the body as shown for half a minute. Then you will know what criminal pressure the spring truss gives. _+Law Should Stop the Sale of Drug Store Trusses+_ We believe the day will soon come when laws will be passed forbidding any one either to fit or sell trusses without a legal license. Just as physicians, surgeons and dentists must all have licenses. So must oculists and opticians, in most states. Also druggists, before they can fill prescriptions. And, unless a man has made a specialized study of rupture-- unless he has a thorough knowledge of it-- he should no more be allowed to sell or fit trusses than a schoolboy should be allowed to practice medicine. Ruptured people seriously risk their health when they trust their cases to any one who hasn't made a thorough, specialized study of rupture. That is almost as dangerous as having a prescription filled by an inexperienced clerk, instead of by a registered pharmacist. For a wrong truss can cause immense harm. [Sidenote: Trusses Should Be Sold Only Under License] When the time comes when trusses can be sold only under license, we'll see most of the self-styled "Hernia Specialists" driven out of business. We'll also see an end to the selling of "stock" trusses by general Mail-Order houses where an order for a truss is handled in exactly the same way-- and often by the same man-- as an order for groceries or hardware. And, when that time comes, mighty few drug-stores will be able to sell trusses. Let us show why. Take the following as an example: A man might _think_ he had only a bad cold. And might go to a drug-store. Now, a druggist doesn't pretend to know _disease_-- he simply knows _drugs_. So about all the druggist could do would be to hand out some patent medicine-- some cure-all. But if the man went out to a good _physician_-- The _physician_ might find, after asking a few questions and thus making a diagnosis, that the patient had _La Grippe_, or _Pneumonia_, or _Pleurisy_ (instead of merely a _cold_, as the patient _thought_). The physician would find out what the patient _needed_, then write a specific prescription-- and seldom the same prescription for any two patients. For the requirements would always _differ_. Or a man might have poor _eyesight_. He might go to an _optician_. Now, an _optician_ doesn't know much about _eyes_-- _he_ has made a special study of _lenses_-- _he_ merely _fits_ glasses-- just as a _druggist_ merely _fills_ prescriptions-- neither pretends to _diagnose_ or _prescribe_. And an _optician_ is just as likely as not to fit a _near_-sighted man with _far_-sighted glasses. [Sidenote: A Truss Fitter Should Know as Much About Rupture as an Oculist About the Eyes] But if the man with poor eyesight goes to an _oculist_-- The _oculist_ finds out what the _trouble_ is-- and what kind of glasses are _needed_-- then _prescribes_ that kind of glasses. And then the _optician fits_ the man according to the _oculist's prescription_. Just as a _druggist_ fills a _physician's_ prescription. Now our method of fitting you by mail is precisely like the physician's method. From your answers to the simple questions we ask on our information blank, we first decide the _needs_ of your case-- then we _prescribe_-- then we _fill_ our prescription by making especially for your case exactly the kind of truss you need. A physician never asks _you_ what _kind_ of medicine _you want_-- he _prescribes_ for you the kind which _he_ knows you _need_. But if you go to a _drug-store_ for a truss, the clerk behind the counter asks you what _kind_ of truss you _want_! You must be your _own_ doctor. [Sidenote: Druggists Know Nothing about Rupture] Neither the drug clerk nor the druggist knows enough about _rupture_ to know what kind of _truss_ you _need_. And, usually, his knowledge of _trusses_ is confined to the difference in _prices_-- he'd rather sell you a $10 truss than a $3 truss. His knowledge of _fitting_ is not much greater. If you measure 36 inches around the hips, he gives you a 36-inch truss-- which, in everything except size, would be exactly like the truss he'd sell at the same price, to a man with a rupture only _half_ as bad as yours, or to a man with a rupture _twice_ as bad as yours. A drug-store sells trusses in exactly the same way that the old-fashioned shoe store sold shoes. It was solely a matter of how much the customer wanted to _pay_, and the _style_ the customer _wanted_-- _not_ what the customer _needed_. Thousands of people have been "all crippled up" because their shoes were too _short_, or too _narrow_, or the _wrong shape_. The old-fashioned shoe clerk knew his _stock_, but he didn't know enough about the customer's _feet_ to know when the customer was _properly fitted_. Just as thousands of people have trouble with their glasses because they were fitted by an _optician_-- "over the counter,"-- instead of having an _oculist prescribe_ for them. And, partly because improperly fitted at drug-stores, and partly because drug-store trusses are usually mere makeshifts, thousands of people are to-day wearing trusses which are doing immense _harm_ instead of good-- trusses which cause the rupture to grow constantly worse. Even if there is any druggist in the country who _does_ happen to know much about rupture and about fitting trusses, he'd have to be a mighty bright man to be able to fit you at all properly with the kind of trusses sold in the average drug-store. Practically all the drug-store trusses are simply some form of the old belt or springs and leg-strap truss-- though sold under hundreds of different names as "improvements." They are usually cheaply constructed-- turned out by machinery in immense quantities. And they are always ready-made "stock" trusses. Each kind made in only one model or style, and the pads in only a few different shapes and sizes. Making mighty scant provision for the wide variation between the ruptures of different people; making mighty little allowance for the fact that what will do for one man won't do at all for another. [Sidenote: Each Man Requires Something Different] Your rupture, when out, may be the size of a hen's egg; your neighbor may have a protrusion almost as big as his head; and a lot of other men with protrusions ranging all the way from one extreme to the other. To say nothing of big differences in other ways besides size. Each of you should have a size and shape of holding pad especially adapted to the needs of your case-- each should have a truss put together especially for you. Else there can be no such thing as continuous, comfortable holding of the rupture. So you see the absurdity of trying to get a comfortably fitting truss at a drug-store, or of expecting to get one that will do much good. Might as well expect all men to be properly fitted in a shoe store which carries only one size and shape of shoe. Or in a hat store which carries only one size of hat. Might as well expect both near-sighted and far-sighted men to see better if both wore the same kind of glasses. And might as well expect common window-glass to improve the eye-sight as to expect common drug-store trusses to do any good. [Sidenote: Just Like Getting Glasses] There is just as much difference in different men's ruptures as in the size and shape of their feet or heads. Just as much variation in rupture as in failing eyesight. And everybody knows that one man may need very powerful glasses, while another needs glasses which magnify only slightly; one may need a double lens, while another needs only a single lens; one may need convex lenses, while another needs concave. All this doesn't mean that it is hard to fit ruptured people, but merely that ample provision must be made for the different requirements. As a shoe store does for men's feet. We have found it necessary to make the Cluthe Holding Pads in 115 different styles, shapes and sizes. And frequently we have to make a special style or size. Thus, no matter what your rupture is like, we can fit you with a Cluthe Truss-- one put together especially for you-- one that will meet your requirements just as well as a shoe store can fit you with shoes, or an oculist fit you with exactly the kind of glasses you need. * * * * * It is for these reasons-- their ignorance of rupture-- that we have never sold the Cluthe Truss through druggists. Trusses are simply a _side-line_ in the average drug-store. Just as _cigars_ are, or "_soft drinks_." A druggist knows all about _drugs_. He has made _them_ his special _study_. But he _doesn't_ know much about _rupture_-- doesn't pretend to-- and can't be expected to. Because he _hasn't_ made a _study_ of it. It took _us_, here at the Cluthe Rupture Institute, over _forty years_ to learn all that we _now_ know about Rupture. _Forty years_ of day-after-day _concentration_ on the _study_ and _treatment_ of Rupture. And during those forty years, we have learned things about Rupture which no one _else_ has _ever learned_-- we have gained knowledge which is exclusively our _own_. And it took many years of scientific study and experiment to perfect the _Cluthe Truss_, and to design the hundreds of different _kinds_, _sizes_, and _shapes_ of Holding Pads which adapt this truss to every form and condition of Rupture known to-day. We have told you this, Reader, to show that placing yourself in our care is vastly different from going to a _drug-store_, or to a mere _dealer_ in trusses or _manufacturer_ of them. And the following chapters will show that even more conclusively. [Illustration: Showing a few of the different sizes and shapes in which the Cluthe Holding Pads are made.] _+Physicians Advise Cluthe Truss Instead of Operation+_ Until they know of something better, most physicians, because of their training, naturally believe in hospital treatment for rupture-- naturally favor operations. But few good physicians would ever advise an operation if they knew of the Cluthe Truss and the world of good it has done. Just as no conscientious physician would ever think of sending anyone to the drug-store for a truss if he knew how much more beneficial a Cluthe Truss is. Too bad, for the sake of their ruptured patients, that more physicians don't know the facts about this truss. Too bad the good news hasn't yet spread among all the profession. However, thousands of physicians all over the country are already familiar with the facts-- thousands have seen the folly of expecting ordinary trusses to do any good-- thousands now know that getting a Cluthe Automatic Massaging Truss and our professional care and attention in connection with it, is a vastly different thing than going to a drug-store for a truss. Just as calling in a physician and having him prescribe exactly what you need for typhoid, grippe, nervous trouble, rheumatism or other sickness, is a hundred times more likely to give you relief than if you go to a drug-store for some patent medicine "cure-all." So far as we know, every physician who has impartially looked into the merits of the Cluthe Automatic Massaging Truss and the care and attention we give has from that time on (unless operation was absolutely necessary) been advising a trial of the Cluthe Truss in all cases of rupture which come under his charge. Among such physicians are many connected with hospitals, who almost invariably advise a trial of the Cluthe Truss instead of an operation; just as they would prefer to cure appendicitis without an operation unless an operation seemed imperative. And many physicians (you'll find the names of some of them in the book "Your Neighbor's Word") are themselves wearing Cluthe Trusses, or have worn them until cured. _+Ruptured People Swindled Out of Thousands of Dollars+_ Look Out for the Deceitful "Don't-Wear-a-Truss" Arguments and the Tricky "Not-a-Truss" Claims Get-Rich-Quick Quacks are year after year humbugging ruptured people out of hundreds of thousands of dollars. The traps they set are cleverly baited. But the bait always consists of misrepresentation and tricky subterfuges. Some style themselves "doctors"-- an insult to the medical profession. Some call themselves "Captain" or "Colonel"-- an attempt to get the sympathy of Civil War veterans. Some try to work on your sympathies by telling you they were themselves formerly ruptured-- that they got their knowledge of rupture by studying their own cases-- that they made a special "appliance" for themselves. But a doctor or surgeon can't set his own arm. And no one can make a scientific study of his own rupture any more than he can perform an operation on himself. And some call themselves Rupture or Hernia "Specialists"-- but never specialized in anything except swindling ruptured people. Some of them make offers like "Free to the Ruptured"-- so worded as to make a man think it means free cure. But all they send you free is a cheap little folder or circular. People who write to them soon learn to know better than to expect something for nothing. [Sidenote: Don't be Fooled by "Appliances," "Methods," etc.] And some try to snare their victims with deceitful "Don't-Wear-a-Truss" talk. Try to hoodwink you into thinking they have no truss to sell. Try to fool you with things they call "Appliances," "Methods," "Discoveries," etc. But the man who puts any faith in such claims soon finds that these so-called "Appliances" and "Methods" are nothing but an adaptation of the old-fashioned truss with belt, band, leg-straps, springs, etc. Nothing but the most worthless kind of a truss masquerading under a misleading name. Some of these "Method" concerns throw in some absurd kind of liniment, salve or ointment-- tell you the secret lies in this "lymph" or whatever they call it rather than in their appliances. But that is nothing more nor less than the rankest kind of fraud. It is folly to suppose any salve, liniment or medicine can possibly cure rupture. Might as well expect them to cure a broken bone. Though they can probably do as much good as the worthless "appliances" they come with. [Sidenote: The Liniment Fraud] When you first apply this "lymph" or liniment, you may feel some stimulating effects; for these lymph-sellers are always careful to tell you to _rub_ the stuff _in_ thoroughly. But the stimulation lasts only a few minutes; and is due to the _rubbing_ and not to the liniment. If you rub with your fingers alone-- without any liniment-- it will do just as much good. This rubbing, while the stimulation lasts, simply proves the value of _massage_. For rubbing with your hands is, in a way, like the massage which the Cluthe Truss gives automatically. But the massage given by our truss is a hundred times more invigorating and strengthening to the ruptured parts than any amount of hand-rubbing. Our truss is giving the _massage_ all day long, while rubbing with your hands can be done only once or twice a day at most, only when flat on your back, and only for a few minutes at a time. Some of these people claim they can cure rupture by means of a plaster-- like the kidney plaster which proved worthless long ago. These plaster venders are careful to avoid saying out and out in plain language that their plaster will positively keep your rupture from coming out-- they make no direct promises or guarantee whatever of holding the rupture. If they cannot guarantee holding, it is nonsense to think any plaster can possibly overcome any weakness like rupture, no matter what kind of _magical_ ointment there may be in the plasters. We have talked of these kinds of people in plain language; we have called a spade a spade. For it is nothing less than a crime the way these men have grown rich by defrauding ruptured people. It is worse than the way wildcat "mining" men have robbed the unsuspecting public. For these rupture swindlers take advantage of people's suffering. [Sidenote: How to Save Yourself from Being Humbugged] But it is easy enough to avoid being fooled-- easy enough to guard against frauds and fakes. And it is easy enough to save yourself from throwing money away on drug-store trusses and other things which may be sold without wrong intent-- but which are utterly incapable of doing any particular good. Simply make up your mind not to put any faith in anything whatever for rupture unless you can get the sellers to agree to let you test it on _Sixty Days' Trial_ and under the protection of a _Money-Back Guarantee_. Make sure that everything is clearly understood-- see that all agreements are plainly worded-- insist on a signed guarantee that your rupture will be held or your money refunded. Any concern which makes or sells a truss or anything else good enough to stand _that_ test doesn't need to resort to misleading claims or subterfuge or trickery of any kind. And _that_-- a sixty days' trial under the protection of our iron-clad money-back guarantee-- is the test we ask you to make of the Cluthe Automatic Massaging Truss. _+Showing How the Cluthe Truss is Held in Place Without Leg-Straps or Other "Harness"+_ [Illustration] These illustrations show the free action of the rear or Suction Pads of the Cluthe Truss. The sole work of these pads is to support the frame which passes around the body. They hold the Truss in position, so the Rupture Pads in front can't slip up or down or away from the rupture opening. These pads rest against the cushion of muscles behind the hips (the muscles forming the rump). The pads are hollow on the under side. This forms a vacuum or suction, which makes slipping or displacement impossible in any position. _+What We Have Done For 290,000 Others+_ At this writing we have treated at our Institute, over 290,000 ruptures. These included all kinds and conditions. Some of them the worst cases in history. Many of these people, in despair, were at the point of undergoing an operation. But the Cluthe Truss made operation unnecessary-- saved the big expense-- saved the terrible risk. Among those we have fitted by mail are many infants from a few months to a few years old. And even these little ones wore the Cluthe Truss in absolute comfort while being made better, while being cured. We don't need to tell you it would be cruelty to put any other truss on children. [Sidenote: From Infants To Men Over 80] We have fitted by mail men and women over 60, 70 and 80 years old. People who had been ruptured for from twenty to fifty years. People who had tried dozens of other trusses. But never found one that would hold. Some were in such bad shape-- in such pain-- that they hadn't worked for years. Some of them, before getting Cluthe Trusses, couldn't walk more than two or three blocks without resting. Could hardly get around at all for fear of bad effects on their rupture. And the Cluthe Truss, with its strengthening massage, has worked thousands of cures in cases apparently hopeless like these. While in those cases where cure wasn't brought about-- or hasn't yet been-- this truss kept the rupture from coming out, and made the rupture better. We keep in touch with all our patients-- our interest doesn't cease until we know they are getting along all right. Yet we have known of only a few cases, including the worst ones, where the rupture ever came out after the first few days' wear of this truss. Think of that-- you who had almost given up hope. You can see for yourself what the Cluthe Truss has done by reading a few of the letters-- all voluntarily written-- which are printed at the back of this book. These letters are only a few out of the thousands we have received. _+Costs More to Do Without It Than To Get It+_ You will find it many times cheaper to get a Cluthe Automatic Massaging Truss than to try to do without one. As long as you put up with worthless makeshifts, you are paying the price of a Cluthe Truss over and over without getting any of its benefits. Probably paying its price again and again in time lost from work or business. For if your rupture never keeps you from putting in a full day-- if you never find it a handicap-- if it never keeps you at home in bed when you should be earning money-- then you are far more fortunate than most ruptured people who don't wear Cluthe Trusses. And as long as you try to get along with worthless makeshifts, you have to keep buying truss after truss, paying out dollar after dollar for new trusses to take the place of those which don't last and those which don't do any good. Thus throwing away in a little while many times more than the price of a Cluthe Truss. [Sidenote: Ordinary Trusses Are a Waste Of Money] As long as you go without a Cluthe Truss, your rupture keeps getting worse-- probably worse now than a year ago-- been getting worse every day. Thus again, you are constantly paying far more than the price of a Cluthe Truss; paying it in wear-and-tear on your health, in the drain on your strength and vitality, in the loss of many of the enjoyments which help make life worth living. Without a Cluthe Truss, your rupture is a constant worry. For a man has to be more optimistic than most ruptured people if he can look into the Future without dread when he knows his rupture isn't getting any better. No man, especially one with a family to provide for, wants to let his rupture make him more or less helpless if there is anything he can do to prevent it. No man wants to be disabled for active work, no man wants to be dependent on others. That has been the fate of thousands who never knew of the Cluthe Truss, or who didn't have the wisdom to try it. But you who read this, now that you know the facts, have absolutely no excuse for ever letting rupture get the best of you. [Sidenote: Don't Let Rupture Get the Best of You] No one's fault but your own, if you now let your rupture keep on growing worse. No one but yourself to blame if you don't take the chance we give you to find out, by trial at our risk, just what the Cluthe Truss can do for you. It will be _our_ loss and not yours if this truss doesn't at least make you a whole lot better. But _your_ loss, not ours, if you neglect to _try_ it. Unless you have already let your rupture become permanently irreducible the probabilities are that the Cluthe Truss can entirely free you from the clutches of rupture, just as it has thousands of others. You have nothing to lose and everything to gain by trying a Cluthe Truss. If it doesn't do any good, we'll take it back and you won't lose any money. [Sidenote: Ends all Expense on Account of Your Rupture] If it does prove beneficial, it will in all probability last as long as you have any need for a truss. For it is mighty seldom that any part of a Cluthe Truss ever gives out, even when, as in incurable cases, it is worn year after year. So once you get a Cluthe Truss, you'll probably never have to pay out another dollar on account of your rupture. The Cluthe Truss costs so little-- only $9 to $14-- that every body not a pauper can easily afford it. Costs so little-- when you consider the good it does-- that no one can afford to go without it. You can get lots of trusses that cost less and some that cost even more-- but one Cluthe Truss is worth a dozen of them. Every thrifty man knows that good _shoes_, for instance, are more economical than cheap ones; for the cheap shoes soon go to pieces, soon get shabby; one good pair would outlast three or four of the cheap ones. Every man knows that good shoes-- shoes that keep the feet dry-- are less expensive in the end than shoes which leak and bring on colds and sickness. [Sidenote: Like Buying Shoes] And every man knows that properly fitting shoes, shoes you can wear with comfort, are worth three or four pairs of shoes which hurt the feet. For no matter how little the uncomfortable shoes cost, you can't get your money's worth out of them if you can't wear them. Lots of people have common-sense enough to think of all these things in buying shoes. But lots of them let their common-sense go on vacation when it comes to buying trusses. Yet a truss is a hundred times more important than shoes. Think how much depends on a truss-- your comfort, your ability to make a living, your safety when working, even your very life sometimes, all depend on your truss. If your truss is no good, if it lets any little strain throw your rupture out, there is constant danger that some sudden wrench, some slip, some fall or misstep, may throw the rupture out so violently as to cause _strangulation_ of the rupture. And that usually ends in quick death. But the man who wears a Cluthe Truss has nothing whatever to worry about. For the Cluthe Truss keeps the rupture from coming out, takes all danger out of work or exercise, takes all strain off the weak ruptured parts, rests them, and-- by automatically massaging them-- daily strengthens them. As the result of this constant hold and in constant strengthening, rupture is not likely to give any more trouble from the day a Cluthe Truss is put on. Just as weak eyes won't bother you any more after you get the right kind of glasses. [Sidenote: Does More for Rupture Than Glasses do for the Eyes] The Cluthe Truss or Cluthe Automatic Massager is the only truss in existence that can be depended on to do for rupture what good glasses do for the eyes. In the majority of cases, it does far more. About all that glasses can do is to keep the eyes from getting worse-- take the strain off them-- rest them, so they won't be further weakened. No one expects glasses to _cure_ weak eyes, no one expects them to improve the sight so much that glasses won't need to be worn. But the Cluthe Truss, in many cases, _does_ cure rupture. You will see proof of that by reading some of the letters at the back of this book. And in those cases where it doesn't result in complete cure, it almost invariably makes the rupture better. If it doesn't do that, we are always ready to refund the purchaser's money, as fully explained in a later chapter. _+X-Ray View of Cluthe Truss+_ Note that there is no Belt, Elastics or Spring around the Waist, and no Leg-Straps [Illustration] This Truss Can be Worn in the Bath, or when Swimming-- All Parts Are Water-Proof This X-ray view shows how simple the Cluthe Truss is-- how few parts it has-- its freedom from uncomfortable "harness"-- and just how it looks when on. This view is taken from above-- what is called a "Bird's Eye" view. The rear pads (Suction Pads) are level with the pads in front (the Automatic-Acting Holding or Rupture Pads), though they seem higher in the picture. Bear in mind that the frame you see in the picture is no way a spring or belt or band. It leaves the hips and spine free-- doesn't press against the body at any point. (This is shown more clearly by the Cross-Section View on page 58.) The Suction Pads in the rear-- which rest lightly on the rump-- hold the truss in proper position, keeping it from slipping, shifting or moving the least bit out of place. The only purpose of the frame is to connect the Suction Pads with the Rupture Pads in front, so the truss can hold you together. The truss shown here is for a severe case of right-side Groin or Scrotal Rupture. Has Automatic-Acting Holding or Rupture Pad on the ruptured side, and a free-acting Protection Pad on the side not ruptured, thus protecting the well side against strains, etc. For Double Groin Rupture, another Holding Pad would be fitted where the Protection Pad is shown here. The Cluthe Automatic Holding Pads are made in over 115 different shapes and sizes, and are selected as the severity and nature of each case may demand. We determine the true nature and real needs of the case from the answers given to the questions on our Order blank, and then shape frame of truss so hips and spine will be left free from pressure, and select Rupture Pad or Pads of the right size and shape, and "set" or adjust the truss so it will be self-regulating in the way necessary to automatically seal the rupture opening to give proper support, and to hold the rupture properly in place. _+The Special Advice You Get in Connection with the Cluthe Truss+_ In every case, we give our complete _Professional Services_. [Sidenote: Like Being Under a Physician's Care] Just as the physician gives thorough study and attention in connection with the medicine he prescribes. Our Professional Service gives you knowledge of your trouble, based on Nature's laws, mechanical laws and common sense, which we have learned during our forty years of day-after-day experience. As a part of our Professional Services, we give Special Instructions-- confidential advice-- based on the individual needs of each case. This confidential advice has to do with your general health, the length of time you have been ruptured, and other conditions having a direct bearing on your rupture. All this costs you nothing extra. And our Special Instructions and Advice are no trouble whatever to carry out. _+Showing How the Cluthe Truss Can't Rub, Hug, Pinch, Squeeze, Chafe, Bind or Irritate+_ [Illustration] Cross Section View, showing how the frame of the Cluthe Truss doesn't press against the body at any point. The Cluthe Truss comes in contact with the body only at the rupture opening (where the Holding Pads support the rupture)-- and at the rear, where the Suction Pads rest against the muscles of the rump. While the frame doesn't press against the body, it fits so closely around the body that the truss won't "show" in any way under the clothes-- no one can tell you have a truss on. Won't even "bulge" a woman's corset-- won't interfere with the corset. Many acrobats wear this truss under their tights when performing, yet no one can see any sign of it. _+Showing the Simplicity of the Automatic-Acting Rupture Pads and of the Massaging Device+_ [Illustration] Illustration at left shows Holding Pad in normal position. When you cough or strain, your abdomen naturally expands, pushing upper end of pad (where finger points in illustration at right) outward, thus forcing the lower part of pad (where arrow points) in against rupture opening. Because of this automatic action of the Holding Pad, your rupture can never come out. [Illustration] The simple mechanism shown on the inside of this pad-- a device so small it would almost go in a watch case-- is what makes the Cluthe Holding or Rupture Pad automatic in its action (self-adjusting, self-regulating). And at the same time, this little device causes the Holding or Rupture Pad to give the strengthening _massage_ to the weak ruptured parts-- all _automatically_ or _mechanically_, like the running of a watch. But-- unlike a watch-- this massaging device doesn't need to be wound up-- never needs any attention whatever; and also unlike a watch, so strong and simple that it can never get out of order-- never fail to work properly. _+Forms and Conditions of Rupture+_ The illustrations on following pages show various stages of the four common varieties of abdominal Rupture. Groin Rupture (Inguinal) is the most common form. Scrotal Rupture (Inguinal) is simply a worse stage of Groin Rupture. The intestines have descended into the scrotum. Navel Rupture (Umbilical) is that form in which the opening occurs at or near the navel. Thigh Rupture (Femoral) is that form of rupture which appears at the upper part of the thigh. Any of these forms of rupture may appear on the right or left side or on both. Our experience has taught us that out of one hundred cases of rupture about eighty-six are Groin or Scrotal Rupture. Thirteen out of each hundred are about evenly divided between Thigh and Navel Rupture. And the remaining one may be one of several uncommon forms not mentioned here because they are usually the result of accident. About half of the cases of rupture occur in childhood. But there are many cases which occur between the ages of 30 and 40. And it is a well known fact that two-fifths of such cases become Scrotal because of neglect, or because a truss is worn that does not keep the rupture from coming down. All ruptures at the start are usually very mild in form. But if the ruptured parts are not held in place, the sac will gradually grow larger because of the failure to seal the originally small opening through which the intestines at first escape. [Sidenote: Warn Those Recently Ruptured] This is something about which you who have been ruptured any length of time, you who know how rupture gets worse if not properly taken care of, should warn any one you may know who has only recently been ruptured. You can save them years of suffering by telling them about the Cluthe Truss. For it so often happens-- due to the general ignorance about rupture-- that newly ruptured people don't know their danger until too late. The rupture often gives so little trouble at first that they think it nothing to worry about. Or perhaps-- also due to ignorance-- they are ashamed to ask anyone's advice. So they go to a drug-store and get a worthless makeshift; and, of course, wearing the cheap contraptions sold by drug-stores, they soon find themselves in a serious state. There are six conditions of rupture. When the rupture can be pressed back into the abdomen by the ordinary manipulation of the fingers, it is a Reducible Rupture. This is the first condition, but without a proper truss it soon grows worse. When only a part of the contents of the lump or rupture sac can be pressed back into the opening, it is known as a Partly Reducible Rupture. This condition is generally the result of neglect of the Reducible Rupture or the use of an improper truss. When at times the contents of the lump or sac cannot be pressed back into the body with the hands, it is known as a Temporarily Irreducible Rupture. This temporarily irreducible condition can often be cured and always prevented from growing worse if the proper truss is fitted and worn. The foregoing condition sometimes becomes so bad that it is known as Permanently Irreducible. But even then it can usually be controlled-- prevented from growing worse-- if the right kind of truss is worn. The condition bordering on strangulation is known as Incarcerated Rupture. The only help for a person in this condition is an immediate operation. The worst condition of rupture is the strangulated form. This is a condition where mortification has already set in. If an operation is not immediately resorted to, the sufferer will die. * * * * * [Illustration: Fig. 1] [Illustration: Fig. 2] [Illustration: Fig. 3] [Illustration: Fig. 4] [Illustration: Fig. 5] [Illustration: Fig. 6] These illustrations show Groin Rupture as it first appears, and how it gradually grows worse and descends into the privates (both male and female) when neglected or not properly protected, as when a worthless truss or other appliance is worn which frequently or occasionally lets the rupture come out. Figures 1, 2, and 3 show the first three stages of Groin Rupture. Figure 4 shows Groin Rupture descended only to the privates. Figures 5 and 6 show the rupture _after_ it has descended _into_ the privates. [Illustration: Fig. 7] [Illustration: Fig. 8] [Illustration: Fig. 9] [Illustration: Fig. 10] [Illustration: Fig. 11 (At Navel)] [Illustration: Fig. 12 (At Navel)] Figures 7, 8, and 9 show advanced stages of Scrotal or Groin Rupture (getting worse all the time because not properly protected, because not kept from coming out) after it has descended into privates. (The different stages are the same in Females as in Males.) Figure 10 shows Thigh or Femoral Rupture, which comes out on the upper part of thigh, just below the crease or depression between abdomen and thigh. Femoral Rupture never appears higher up-- never appears in groin, and never descends into privates. Figures 11 and 12 show two stages of Navel Rupture. (For Cluthe Navel Truss, see page 64.) We make the Cluthe Truss with special Holding Pads that meet the requirements of every one of the foregoing conditions of Rupture, save Incarcerated and Strangulated. With the exception of these two forms we guarantee that the perfect truss with Automatic Massage Treatment will constantly hold any rupture in place. Navel or Umbilical Rupture (which appears at or near the navel) demands immediate treatment. [Sidenote: Navel (Umbilical) Rupture] Neglect or Mal-Treatment is liable speedily to treble the size of the rupture. We make a special Cluthe Navel Truss which has never in any case failed to improve the condition from the moment it was applied. Our Navel Truss does not bind the abdomen-- allows perfect freedom-- is light, clean and comfortable even in the hottest weather. It is the only successful holder for Navel Rupture-- the only one that supports the overhanging weight in front without the use of torturing elastic fabrics. Cases of Navel Rupture demand special care, for hardly any two are alike. So we cannot prescribe for Navel Rupture until we know your condition. Simply write us stating whether the rupture can be fully reduced. If it can't, give size of part that cannot be reduced. If none of the forms of Navel Rupture shown on the order blank seems to be about the size of your rupture, and in the same location, please mark on the picture as nearly as you can the size and location of your rupture. On receipt of such report, we shall advise you as to the appliance needed, and its price. * * * * * [Sidenote: After Operations] For recurrence of Rupture after an operation, we make the Cluthe Truss with special frames and pads. For the requirements in each case are usually different. Simply fill out the order blank, and we will tell you just what you need, and the price. _+Let Us Send You A Cluthe Truss On 60 Days' Trial+_ Won't Cost You a Single Cent if You Don't Get Better We don't ask you to risk a single cent of your money in finding out what a Cluthe Truss can do for you. We have so much faith in our truss-- we know what it has done for so many others-- that we are willing to make a Cluthe Truss, as explained below, especially for your case, and let you wear it sixty days on trial. Think of that, Reader! When you get a truss at a drug-store or truss dealer's, the only chance you have to make a test is _while trying the Truss on_. But the sixty days' trial we allow you certainly gives you plenty of time to make an absolutely thorough test-- plenty of time to see whether the truss is doing any good-- plenty of time to make sure that, with this truss on, your rupture can't come out-- plenty of time to prove the wearing and water-proof qualities of our truss. _Sixty days_ is longer than lots of trusses or "appliances" would last! [Sidenote: 60 Days Is Longer Than Lots of Trusses Would Last] Longer than you could stand to wear any truss which pinches or squeezes or hurts in any way! We'll protect you by giving you our signed guarantee (this paragraph in itself is a guarantee) that this truss will keep your rupture from coming out and improve your condition when put on and worn according to our simple directions; guarantee it to prevent protrusion, not for just a few minutes at a time, but for all day long, including when you are working, exercising, taking a bath or swim. If, after fair trial-- whether at the end of ten days, thirty days or sixty days-- you find that the truss isn't holding your rupture, isn't helping you, simply let us know what the trouble is and if we can't correct it we'll promptly refund your money. Our willingness to let you try a Cluthe Truss sixty days entirely at our risk is the best proof in the world of its merits. We could never afford to send you a Cluthe Truss on such a long trial if there were any likelihood that it wouldn't prove beneficial, any likelihood that you would want to return it. But the Cluthe Truss has been put to the test so many times, including hundreds of seemingly hopeless cases, that we know our faith in our truss is justified. [Sidenote: Benefits 199 Out of Every 200] Counting all the thousands of people who have placed themselves in our care, our records show that the cases in which a trial of the Cluthe Truss failed to prove beneficial have averaged only one out of each two hundred. A really remarkable record. For among the people who have tried the Cluthe Truss, among those cured by it, are hundreds who had been ruptured over 50 years. Note letters in back of book and the 5,000 names you'll find in "Your Neighbor's Word." The law of averages always holds good; it is one of the most certain things in the world. And when 199 out of every 200 who have tried this truss were benefited, and many of them cured, you can see that there are mighty few people who can't expect a Cluthe Truss to do them a lot of good. Bear in mind that we aren't claiming that every one who has tried a Cluthe Truss has been completely cured by it. We would rather err by claiming too little than claim too much. Even a common cold, about the simplest of all human ailments, can't always be cured, can't always be so much as relieved or checked; that is why a cold, in spite of everything that can be done, so often develops into pneumonia, bronchial trouble, etc. But we do stand back of the Cluthe Truss with an absolute guarantee that it will keep the rupture from coming out, enable you to work without danger, and result in improvement. Surely no man can expect a stronger guarantee, especially after what many have gone through with other trusses. Note that our guarantee is in plain, straightforward language-- you know exactly what it means-- no evasions, no subterfuges-- an iron-clad and absolutely legal guarantee. [Sidenote: Our Guarantee Protects You Absolutely] It is nothing like the tricky, hoodwinking guarantees which so many other concerns give. Beware of a so-called guarantee which merely reads "This truss fully guaranteed." A guarantee-- as any lawyer will tell you-- isn't worth the paper it's printed on unless it guarantees something specific, such as holding. And it gives you no protection unless it guarantees your money back in case of failure. But our Guarantee is a positive Money-Back Guarantee. If the Cluthe _Truss_ fails to "make good," then _we_ will "make good" by refunding your money. You don't need to worry about that for a minute. No one dependent on the good will of the public could remain in business as long as we have, now over 40 years, and constantly gain new friends through the old, unless every customer received a square deal. Dishonesty would have driven us out of business long ago. We believe that our reputation for absolute fairness and honesty is as firmly established among people who have had dealings with us as the reputation of Wanamaker's or Marshall Field's. We are so seldom asked to refund money that it would be the height of folly to risk injuring our reputation for the sake of the few dollars represented by a Cluthe Truss or even a thousand trusses. If we were selling automobiles or shoes or hardware, our honesty would be taken for granted. But there has been so much trickery in the sale of trusses and other things for rupture that it is only in justice to ourselves that we mention our reputation. [Sidenote: Your Money Simply Held on Deposit] Remember that we protect you at every point. And our interest in your case won't cease until we know you are getting along all right; you'll always find us ready at any time to do everything within our power. So don't let another day go by without trying this truss, this truss which has done wonders for others. Remember that all money you pay is simply held on deposit until you have made the 60-day test. If you have any doubts about our responsibility, have your local bank look us up in Bradstreet's or Dun's. _+See How Little it Costs to Get Relief+_ If you had to pay for the world of good a Cluthe Truss does, the price would be many times higher. But we charge only for the materials and time which go into the truss, plus a legitimate profit. There is nothing fancy about a Cluthe Truss, for you don't wear a truss for ornament. But the minute you see it, you will know you are getting your money's worth. It is the strongest truss ever made-- and at the same time the lightest; also the cleanest, neatest-looking. Made of the best materials we can buy-- materials which will last. So well made that the cost of making a single part-- such as one of the Holding Pads, the massaging device or the self-adjusting feature-- is greater than the cost of making most other trusses complete. So strongly made and so simply made that there is nothing about it likely to get out of order. * * * * * [Sidenote: About Prices] We make the Cluthe Truss or Cluthe Automatic Massager in two grades. Both are precisely the same in principle and in action. Both are fully guaranteed to hold your rupture securely. Both are perspiration-proof and both water-proof. The Cluthe Truss-- either grade-- is the only truss made that you don't have to remove while taking a bath or swim and that insures perfect holding at _such_ times as well as at all other times. Our Grade A is the best wearing truss-- the most durable truss made. If you get this truss, you'll probably never need to pay out another dollar on account of your rupture. Frames and pads are both covered with water-proof Vulcanized Rubber (unless you prefer water-proof Cushion Holding Pads). And now note that the Cluthe Truss costs little or no more than many other kinds which are nothing but makeshifts. The price of Grade A, for single rupture, is $12. For double rupture, $14. Grade B, for adults with hip measurements 28 inches or larger, is $9 for a single rupture. For double rupture, $11. For children, up to 27 inches hip measurements, this grade for single rupture is $6. For double rupture, $8. [Sidenote: Only $9 to $14] Grade B will outlast a dozen ordinary trusses. But it isn't as durable as Grade A. The frame is covered with special Waterproof Casing. Holding Pads on Grade B Truss are the same as on Grade A-- vulcanized rubber or water-proof Cushion Pads. We advise Grade A, simply because this is more durable. Both grades are for Groin or Scrotal Rupture only. For Navel Rupture, or After Operation, see page 64. In fitting either grade, we give equal attention and care-- give you our complete Professional Services, special instructions and our confidential advice. And on both grades give you sixty days' trial and the protection of our money-back-guarantee. * * * * * The prices quoted here are for Mail Order Fitting only. Our charges for Fitting by appointment at the Institute will be furnished upon request. Previous appointment for personal fitting at the Institute is _absolutely_ necessary. Our terms are Amount with Order. As explained elsewhere the amount is simply held on deposit until you have made thorough trial of the truss. _+Don't Let Yourself Keep on Getting Worse+_ There's no Better Time Than Right Now to Put the Cluthe Truss to a 60 Days' Test Don't wait till the last minute-- don't wait till your rupture makes you absolutely helpless-- don't wait till good-for-nothing trusses cripple you up so you can scarcely drag around at all-- don't wait till it's too late for a Cluthe Truss, an operation or anything else to save you. Don't cheat yourself out of making a sixty-day test of the Cluthe Automatic Massaging Truss-- don't rob yourself of this chance to get relief without having to risk a single cent of your money. Even though you may think your condition is hopeless, don't let that keep you from trying a Cluthe Truss-- don't let anything whatever keep you from finding out what this truss can do for you. [Sidenote: You'll Begin to Get Better Right Away] Unless you are far worse off than most others who have tried this truss, you'll begin to get better from the day you put a Cluthe Truss on. You'll have nothing more to worry about-- you can work your hardest every day in the week-- take any kind of exercise-- take your bath or swim, etc.-- all without the slightest danger of forcing your rupture out. [Sidenote: No More Torturing Harness] And no belt, band or springs around the waist, no leg-straps, no pressure on the spine or the pelvic bone. Nothing that can squeeze, pinch or bind, nothing that can heat, chafe, itch or cut the skin, nothing that can irritate in any way. Constant holding every minute of the day, and day after day, and the soothing, strengthening, invigorating massage which the Cluthe Truss automatically gives, will soon make a new man of you. We won't accept your order, won't take your money, if we don't think, after making a study of your case from the particulars you give when ordering, that a trial of our truss will prove beneficial to you. Your rupture will prove far worse than the average man's, your condition worse than that of 199 out of every 200 who have tried this truss, if the Cluthe Truss doesn't do you a lot of good. Just give a few minutes attention to the 5,000 voluntary endorsements of the Cluthe Truss which you'll find in "Your Neighbor's Word"-- See how many of the people whose names and addresses you'll find there live right in your own town or county or state. Read a few of the letters-- all voluntarily written-- which we print at the back of this book. See how many very severe cases have been completely cured by the Cluthe Automatic Massaging Truss-- many of them cases of from thirty to fifty years standing-- many of these people cured (while _working_, remember) in from three to ten months-- many of them cured after everything else, including operation, had proved utterly useless. There isn't a single reason in the world for condemning yourself to drag through even another month with your rupture everlastingly bothering you-- And not a single reason for longer enduring the curse of wearing a truss which is doing no good or which hurts so it keeps you in constant misery. [Sidenote: Why Remain a Victim of Good-for-Nothing Trusses?] Every day that you remain at the mercy of a truss which either occasionally or frequently lets your rupture come out is simply a day of danger. You can gain nothing whatever by waiting-- by trying to get along without a Cluthe Automatic Massaging Truss. And you risk nothing whatever-- not a single cent-- by testing the Cluthe Truss on sixty days' trial. Better make the test right now-- if you put it off you simply face the danger of getting worse all the time. Chas. Cluthe & Sons CLUTHE RUPTURE INSTITUTE Bloomfield, New Jersey (A Suburb of New York City) _+How to Order+_ First decide which Grade of the Cluthe Truss you want to try. (See pages 68 and 69.) And please don't forget to enclose the necessary amount with your order. (This amount, as explained elsewhere, will simply be placed to your credit and held as a deposit in your name while you are testing the truss on 60 days' trial.) The best way to send the amount is to get a draft at your bank, or get a Post Office Money Order or Express Money Order. If currency is sent, be sure to register your letter. In ordering, please use the Information or Order blank which we enclose with this book. Be sure to sign your name plainly, and give your full address. Be careful to write out plainly as you can a full and complete answer to each of the simple questions we ask on the Order blank-- remember that your answers guide us in determining the requirements of your case, the size and shape of Holding Pad or Pads, the amount of support you need, and the point at which to "set" or adjust the truss so it will automatically give the right amount of support or holding power. If there is any further information you want to give us, write it in the space under "Remarks" on the Order blank, or on a separate piece of paper. If you happen to mislay the order blank, just use a separate sheet of paper for writing out your answers to the questions given below. (Instead of taking the trouble to write out both questions and answers, merely give the answers alone, and number the answers 1, 2, 3, etc., to agree with the corresponding question.) These Questions are the Same as on Order Blank 1. Which of the figures shown on pages 62 and 63 most resembles your Rupture, when fully out-- On your right side? On your left side? 2. Give measurement around naked body in direct line over place where rupture first comes out. 3. Male or female? 4. Age? 5. Height? 6. Weight? 7. Occupation, and does your work require heavy lifting? 8. Where is your rupture located? (State whether right, left, or both sides, or at navel.) 9. If on both sides, which is worse and which harder to hold? 10. When rupture is out how does it compare in size to pigeon's, hen's, or goose egg? (If two ruptures, give size of each.) 11. Has your difficulty been to get a Truss to hold? 12. If male, does your rupture descend INTO the scrotum? 13. If unsuccessfully operated on for rupture-- or if rupture is result of an operation-- mark on a rough sketch or on a trace of the figure most resembling your rupture the comparative location of _incision_. 14. How many years ruptured? Address Chas. Cluthe & Sons, Bloomfield, New Jersey. _+Testimonials+_ +Prominent Arkansas Physician Cured of Rupture of 49 Years Standing in 8 Months by Cluthe Truss+ With pleasure I beg to submit the following facts in my own case at which I was greatly surprised. I am 53 years old, and was badly ruptured when 4 years old, on both right and left sides. The right side rupture failed to be held by any and all kinds of trusses until I put on a Cluthe Truss. I can now remove the truss and feel no symptoms of Hernia. Now, how is this for a cure in eight months? I take pleasure, as a physician and surgeon, in recommending the Cluthe Truss to any and all sufferers from Hernia. I have fitted Cluthe Trusses on four other patients, three of whom are already well and the fourth greatly improved. You have my permission to use this testimonial as you please, and I hope it may be the means of others, suffering from rupture, resorting at once to a Cluthe Truss. October 4, 1911. J. H. SPURGEON, M.D., Aurora, Ark. +From a Prominent New York Plumber+ After trying a drug store truss and a strap without getting either to hold my rupture, which was getting larger all the time, I tried a Cluthe Truss, which has worked wonders in my case. In my work as a plumber I have to get into every conceivable position, often tie up in a knot, as it were, but my Cluthe Truss never failed; never shifted a fraction of an inch. I often go without my truss without the slightest sign of rupture or feeling of weakness. After what I suffered and considering the size of my rupture before I was lucky enough to hear of you, you can realize how strongly I can recommend anyone ruptured to send for a Cluthe Truss and save the money he would waste in buying any of the makeshifts. HUGH J. BRADY, December 22, 1911. 863 Sixth Ave., New York City. +This Man, 72 Years Old, Cured in a Few Months by Cluthe Truss While at Work+ When I was first ruptured I bought a truss and tried to wear it. This was fitted by a local dealer time and time again-- but I could not wear it. I then tried another local dealer with the same result. I was then induced to try another truss but could not get any relief. Then, I noticed your advertisement. It seemed impossible to me then that you could do by measurement, which I was to send you, what the local dealers could not do when I was personally present. However, I did send for your truss, expecting only to get a truss that I could wear with comfort. I wore it some months-- after a while I would forget to put it on, and would go for a day or two without it. Each time I would go longer without it-- then some weeks I discarded it entirely. I consider that I am entirely cured of my rupture. I cannot express to you how grateful I am to you and without solicitation on your part I am writing you this letter to show you my appreciation of your efforts. I am now 72 years of age, a mason by occupation and am working every day. J. F. BYAM, October 12, 1911. 701 Cherry St., Rome, N.Y. +This Man from Missouri Quickly Cured by Cluthe Truss+ I gladly testify to convince people suffering from rupture that the Cluthe Truss was a sure cure in my case. Experience has convinced me that if anyone ruptured will apply a Cluthe Truss according to the directions it means positive relief, and the only hope for a cure. I cannot recommend the Cluthe Truss too highly. CHAS. BECKER, October 5, 1911. 3730 Marcus Ave., St. Louis, Mo. +Ruptured for Years-- Tried Cluthe Truss-- Cured in Two Months+ I had worn several kinds of trusses, which did me no good, but, on the contrary, made me worse all the time. I saw your truss advertised and sent for one to try. I felt better at once. I had suffered for years before, and wore the Cluthe Truss a little over two months; then I did not need a truss any more. Now, I feel all right, and if anyone wants to know what the Cluthe Truss can do for rupture refer them to me, and I will truthfully tell them what it has done for me. OREN BACON, November 3, 1911. R.F.D. No. 12, Erin Road, Medina, N.Y. +Cannot Say Too Much for the Cluthe Truss, which Completely Cured His Rupture+ I am more than glad to recommend your truss at any time. I cannot do too much for the Cluthe folks. My rupture is a complete cure and I have you to thank for it. ALEXANDER BRINK, October 5, 1911. Matamoras, Pa. +Cured of as Bad a Scrotal Rupture as Anyone Ever Had+ I take pleasure in informing you that the Cluthe Truss cured me of as bad a Scrotal Rupture as anyone ever had. I thank you for what you have done for me. HENRY B. PALMER, December 3, 1911. 15 5th St., Glens Falls, New York. +This Man 70 Years Old Cured by Cluthe Truss+ I am glad to add my testimony as one who has been cured by the Cluthe Truss. I did not get one with the expectation of being cured, as my rupture was very bad, and I was 70 years of age. I would advise any person, be they young or old, who are afflicted with rupture, not to delay trying a Cluthe Truss and no other, for I have tried many of the others and found them of no good. STEPHEN E. BURGESS, December 2, 1911. Canning, N.S., Canada. +This New York City Man has had No Need for Trusses for 2 Years+ My troublesome rupture was perfectly held in place from the day I wore my Cluthe Truss until I found it unnecessary to longer wear the truss, and I have not had a truss on for nearly two years. I consider the Cluthe Truss the best in the world and I am glad to testify as per the above. FRED. M. WILLIAMS, c/o W. D. Power & Co., 601 West 33rd St., New York City. December 22, 1911. +Rupture Now Cured and has No More Need of a Truss+ I have no more need of a truss of any kind, for I am entirely cured of my rupture, and the Cluthe Truss did it. You can use this if it will help anyone else afflicted the same as I was. I haven't worn my truss for some time. L. H. WALCUTT, December 29, 1911. 509 E. Oak St., Masillon, Ohio. +This Arkansas Man Cured by Cluthe Truss After Suffering 20 Years+ I cheerfully recommend the Cluthe Truss to anyone suffering from rupture. It is the only one I have ever seen, had or heard of that does the work thoroughly. I am practically cured of my rupture through using the Cluthe Truss, after having suffered for 20 years. It is because it is the only truss that will absolutely prevent the rupture from coming down. W. B. CURTIS, October 2, 1911. Haynes, Ark. +Cluthe Truss Saves These Two from Surgeon's Knife+ My wife was saved from the knife after a wild midnight ride to the House of Mercy in an ambulance. We can never say too much for the Cluthe Truss. My wife was ruptured for 11 years and suffered great pains at times. We are both nearly cured. She has worn her Cluthe Truss since June of this year and I have worn mine since last Christmas. Many thanks to the Messrs. Cluthe for their wonderful truss. MR. AND MRS. D. CHAMBERLAIN, September 26, 1911. 272 So. Dalton Road, Pittsfield, Mass. +A Man 79 Years Old Practically Cured in 3 Months+ I have worn your truss about three months and it is worth its weight in gold. I believe I am cured. I forgot to put the truss on different occasions and did not notice my rupture or feel the slightest weakness. I am working every day. The other trusses I wore only made me worse. I shall still wear my Cluthe Truss-- I would not take any chances just now. I shall be pleased to recommend it to everyone ruptured. JOSEPH DOBINSON, 381 Harvard St., Cambridge, Mass. October 10, 1911. +Soon Cured and Never Used Truss Since+ I verily believe that your truss is the best of all the trusses made, for after less than a year's use of the Cluthe Truss I laid it away and never had to use any truss since. Hoping that all who have suffered as I have in the past from rupture may find relief from this terrible affliction. J. C. DE MOTT, 5 West Long Ave., Du Bois, Pa. October 3, 1911. +New Lease of Life for This Man+ I found the Cluthe Truss as different from all other trusses as a scientific balance is to a vise. I am 70 years old and have always been unable to take long walks, but the first Sunday I had your truss I walked a mile to my house and felt so good that I walked three miles more. Prior to getting your truss I could not walk half a dozen city blocks without great distress. I wish you great success towards suffering mankind. JOHN DIVINE, 1238 Wisconsin Ave., N.W., Washington, D.C. September 6, 1911. +Had Probably the Largest Display of Trusses before He Tried the Cluthe, Which Alone Holds+ Some months ago I was induced to make just one more venture in buying trusses. I admit that I had but mighty little faith, in fact I was well nigh discouraged. I had probably the finest and largest display of trusses of any man in the country, but none of them would hold my right side rupture. How thankful I am I tried just once more, and bought the Cluthe Truss! It holds splendidly and is so easy to wear that it gives me no trouble whatever. H. C. VANDERHOEF, Belmont, New York. December 19, 1911. +Man 76 Years Old Cured+ My rupture has been entirely cured by the Cluthe Truss, and I have been without a truss for over a year. What this means, I alone can appreciate, as I am 76 years old. CHAS. A. STEIN, 210 Catharine St., Elizabeth, New Jersey. December 22, 1911. +Tried All Remedies; Only the Cluthe Could Cure Him+ After suffering 5 years from rupture and trying all the remedies and trusses I could get (all of them failed) finally I ordered a Cluthe Truss, and now I am entirely well. I cannot find words to praise the Cluthe Truss high enough. Thanks to you for the benefits enjoyed from the best thing ever made for rupture. ELISHA A. HARTMAN, Terre Alta, W.Va. December 19, 1911. +This Brooklyn, N.Y., Man Cured+ Let ruptured people know that the Cluthe Truss cured me of my rupture, and that I now have no need for a truss of any kind. GEORGE DIEFENBACHER, 90 Fountain Ave., Brooklyn, N.Y. December 22, 1911. +Now Well and Strong as She Ever Was+ I want to thank you for your help. Your Cluthe Truss has cured me completely. I am as well and strong as I ever was. You may use this, for I think anyone afflicted as I was would consider it a great blessing to know how to be cured without an operation. MRS. WALTER De LONG, 814 North Cherry St., Galesburg, Ill. March 28, 1911. +Practically Cured in a Few Months+ My rupture is cured, thanks to your truss. I could take my truss off now, but I am going to keep it on a little while longer. D. M. DAUGHERTY, 532 So. Fairview St., Lock Haven, Pa. October 4, 1911. +No More Need for Trusses Now+ After wearing truss about six months I found I did not need it any more and have used none since. From your grateful friend, ISAAC H. ELLIOTT, Waterbury, Vt. October 29, 1911. +This Texas Engineer Gets Instant Relief by Cluthe Truss After Suffering 35 Years+ I would not take one thousand dollars and do without your truss if I could not get another exactly like it. I was ruptured July 6, 1876, and have bought all kinds of trusses and things for rupture-- but could never get one to hold me. My rupture had just about put me down and out, but now I can ride, lift, do any kind of work, get into all positions and the Cluthe Truss keeps me held without the slightest discomfort. Just think of it-- I had suffered since the year 1876 and only since I have had my Cluthe Truss did I get any relief. I am a railroad engineer and train man, a member of the B. of L.F. and E. and I am well-known over much of Texas and Mexico. I cannot make my recommendation too strong. O. R. ERWIN, Mabank, Tex. September 30, 1911. +Practically Cured-- Recommended Friend Delighted+ My rupture has not been out since I got my Cluthe Truss. Sometimes I have taken off my truss and walked around but do not see any indication of the rupture coming out. I suffered so much wearing ordinary trusses, which made my rupture larger and larger, that I do not feel like doing without your truss yet. I consider myself cured but my truss feels so good I do not go out without it. Through my recommendation a friend got one of your trusses and he is delighted. W. W. GARDNER, West Paris, Maine. October 4, 1911. +Gained 60 Pounds Since Cluthe Truss Cured His Rupture+ The Cluthe Truss positively cured me of a very bad rupture. I have gained 60 pounds since I was cured and am now in the best of health. W. H. KAMMERER, 3842 N. 6th St., Philadelphia, Penn. January 6, 1912. +Considers Cluthe Truss More Than a Success in His Case+ I have worn about all kinds of things for rupture that have been made during the last 25 years and have spent lots of money on them, and can truly say I never had a moment's let-up of pain until I wore a Cluthe Truss. After making the readjustment you advised I would not know I was ruptured, the Truss has been so comfortable. Mine is a severe case of rupture, being quite large. Before I got your truss, my rupture would at times keep me in bed for days at a time. There is only one trouble with people who are ruptured. They are wrongly advised and fly to a druggist and buy a truss like a cigar (I have bought lots of them that way). Then they think all trusses are alike. When I read your advertisement, I had no more faith in you than in any of the rest of them that sell trusses under all sorts of different names. The result of my transaction with you, however, is that I consider that I drew a prize in my Cluthe Truss, and I want to say that you are the first Truss men that ever lived up to their agreement that I ever found. Your truss has held me from the day I received it, April 20, 1911. I could not walk a quarter of a mile before I got it, and could lift no more than a hod of coal. After I had the truss two weeks I could carry a barrel of flour. I have done my garden digging, mowed a lawn, and even raised a 30 ft. ladder all alone. It would take more than a thousand dollars to-day to buy my Cluthe Truss if I couldn't get another like it-- that is how I value it. Before I tried your truss my body was full of callous places, made so by the other appliances I wore, but they are all gone now, thanks to the Cluthe Truss. I feel better to-day than I ever have in years. I have written you to some length, but I do it with pleasure. JOHN C. BAILEY, 75 John St., Newport, R.I. January 1, 1912. +Counts Himself Lucky in Having Heard of Cluthe Truss+ I can assure you I count myself lucky in having answered your advertisement, which I saw in an old paper, for I owe my present cure to you, and I thank you heartily. I will be glad to speak a word of recommend whenever possible, for I know you are doing good work for humanity. WALTER FRANSEEN, Woodhull, Ill. October 13, 1911. +Now Safe and Sound and Needs No Truss+ I wish to say that your truss has effected a permanent cure of my rupture. I have lately gone without my Cluthe Truss without the slightest trouble or inconvenience. LOUIS FRIDAY, 4 Steuben St., Schenectady, N.Y. October 13, 1911. +Believes He is Cured by Cluthe Truss+ I believe I am cured, but as I am doing heavy work I am not going to take the chance just yet to prove it, until I have lighter work to do. JAMES W. GRANT, Creede, Colo. September 26, 1911. +Worst Ruptured Man in Town Completely Cured in 5 Months+ Have been thinking for some time about writing you, how the truss I got of you last April was working. I am happy to inform you that I could throw the truss off altogether without any danger of my rupture coming out. It was said that I was the worst ruptured man in town. It was almost as large as a cocoanut-- I could not get a truss that would hold it up. I could not go anywhere, I was in pain most of the time. The doctor told me I could never get a truss that would hold me. Several times my daughter went to the 'phone to call the doctor to operate on me, but the Cluthe Truss saved my life. I would have paid any money for it. I recommended your truss to my brother-in-law and received a letter from him yesterday in which he says that it is the best investment he ever made. What I write you I can truthfully tell to anyone ruptured. You can use this letter as you see fit. J. H. GODDARD, 747 E. Main St., Ravenna, Ohio. October 4, 1911. +Glad to Pass This Cure on to Any One Afflicted+ Before using the Cluthe Truss I had a rupture that was never in place. It troubled me in a great many ways, and it was also very sore at times. I had to put my hand in my pocket and push the rupture back into place repeatedly during the day, and glad to state that the Cluthe Truss cured this troublesome rupture, and I am only too glad to pass your cure on to some person who is afflicted as I was. WM. HUNTER, 101 Cleveland St., Central Falls, R.I. October 20, 1911. +This Man Cured by Cluthe Truss After 14 Years of Suffering+ I can never forget the good the Cluthe Truss has done for me. After 14 years of suffering I tried the Cluthe Truss, which entirely cured me. It is now three years since I have worn any truss at all. It took your truss only one year to cure me and make a new man of me, after everything else I tried had failed. DANIEL R. WRIGHT, Little Neck, L.I., New York. January 1, 1912. +Another of the Thousands of New Yorkers Cured by Cluthe Truss+ I have not worn my Cluthe Truss since last June, and have been doing hard work and heavy lifting without even feeling the strain of work. In fact I feel just as if I had never been ruptured or worn a truss in my life. LOUIS BERNET, 443 St. Ann's Ave., (Bronx), New York City. December 28, 1911. +Cluthe Truss the Only Relief After Suffering and Searching 35 Years+ I had been ruptured all my life and am now 35 years old and never could get anything that would give me relief from my rupture sufferings until I got a Cluthe Truss. To-day I could go without my truss, because it has cured my rupture. W. R. BUCK, Upper Marlboro, Md. October 4, 1911. +Cured by Cluthe Truss-- His Rupture No Longer Appears+ I will gladly do anything in my power to help another sufferer, that is why I can say to all that the Cluthe Truss is the easiest truss to wear I ever had, and I have tried many. My rupture has not appeared for the last two months, so the prospects are that I am cured. ADAM BREHM, 609 No. Garfield Ave., Burlington, Iowa. September 29, 1911. +Has Not Worn a Truss for 2 Years and is as Sound as He Ever Was+ The Cluthe Truss is the best thing for rupture that I ever heard of. It cured me of my rupture completely. I have not worn a truss of any kind for 2 years, and am as sound to-day as I ever was, all through the use of your truss. JAMES H. RODENBOUGH, 162 Bayway St. Elizabeth, New Jersey. December 26, 1911. +The Cluthe Truss Entirely Cured Him+ I wish to state that your truss has entirely cured my rupture. You may refer any person to me at my address. H. CRANE, 26 Mynderse St., Schenectady, N.Y. October 19, 1911. +Has Not Needed or Worn Any Truss for Months+ I have not had my Cluthe Truss on for the last 4 months, and my rupture has not shown or bothered me in the least. Your Truss has certainly cured my rupture. I had three other kinds of trusses before I got yours and could not wear any of them, because they hurt me so. ERVIN S. COLE, R.F.D. No. 3, Norwich, N.Y. October 13, 1911. +Says Law Should Be Passed to Stop Sale of Drug Store Trusses+ Your truss has cured me. At least my rupture never comes out when I have the truss off for 2 or 3 hours at a time. I think your truss is the only perfect device for rupture made. There ought to be a law passed prohibiting drug stores from selling those so-called trusses that don't hold or give a man a minute's peace. J. C. HOUSEMAN, 813 No. 18th St., East St. Louis, Ill. October 26, 1911. +This Retired Railroad Man Cured by Cluthe Truss+ Use my name in the hope that it may benefit some one afflicted as I was, but now restored. H. B. HAMMON, Bristolville, Ohio. October 26, 1911. +Believes He is Cured After a Few Months Wear+ I have not missed wearing my Cluthe Truss a day since I got it. I believe I am cured, but as I had so much trouble before I got your truss, I thought I would wear it a little longer, as it does not bother me in any way. A. S. HOLLOMON, Trimble, Tenn. October 9, 1911. +Says Results Have Proved Good Judgment of His Faith in the Cluthe Proposition+ I could not exaggerate the facts in connection with the great good secured to me from the use of the Cluthe Truss. I have had more pleasure in life since using your Truss than during all the 50 or more years before. The very minute I read your proposition I knew you were on the square and onto your job and I made no mistake in my judgment. CHAS. W. SHIVELL, c/o West Hotel, Minneapolis, Minn. November 18, 1911. +Wonderfully Benefited+ I have been wonderfully benefited, perhaps cured, by using the Cluthe Truss, and would suggest to every sufferer from rupture to throw away all other trusses and secure a Cluthe, as they cannot possibly make a mistake in its use. My truss is as good now as the day I received it from you. J. C. HERSHBERGER, West Church St., Williamsport, Md. October 4, 1911. +Feels No Trouble Whatever from Either Rupture+ I still wear the double truss I purchased last March. I think I am cured, as I feel no trouble whatever from either rupture, but the truss is so comfortable I have continued to wear it. C. A. HAZEN, Woodsville, N.H. September 30, 1911. +This Newark, N.J., Man Cured of Worst Kind of Scrotal Rupture by the Cluthe Truss+ Your great truss cured me of a scrotal rupture of the worst form, after years of suffering, having tried at least 20 other makes of trusses, etc., which did me no good except caused me more suffering. I wish you continued success in aiding suffering mankind. F. A. ZIPF, 47 Tichenor St., Newark, New Jersey. December 29, 1911. +Cluthe Truss Freed Him From Pain at Once-- Now Cured+ I feel I am cured of my rupture but continue to wear the truss for protection. I never had any benefit whatever from any other appliances I ever tried. In regard to the Cluthe Truss, I feel as though I was in Heaven (as it were), as it freed me from pain at once. JOHN B. TIGER, 829 E. Jersey St., Elizabeth, New Jersey. December 23, 1911. +The Cluthe Truss the Only Help He Found for His Rupture+ I will gladly tell anyone suffering from rupture that I am more than pleased with my Cluthe Truss. Of all the things I have tried for my rupture, the Cluthe Truss is the only thing that ever helped me. I believe it will cure me entirely. I have not felt the slightest pain since I put the truss on. W. F. BOSTEN, 1113 Oregon St., South Muscatine, Iowa. September 22, 1911. +Found Cluthe Truss a God-send+ I have worn your best grade truss since last March. It has given me perfect satisfaction as well as to my friend, Mr. R. M., a man 82 years old, to whom I recommended your truss. Before I tried yours I wore one ordered by my physician. It caused me great suffering, and I was unable to do any lifting or stooping whatever. The doctor then informed me no truss could help me. I then happened to hear of the Cluthe Truss, which I ordered and has been a God-send to me. I am able to work every day. You can use this letter in any manner you see fit. FRED A. HALBERT, 716 Logan St., La Crosse, Wis. September 26, 1911. +But for Cluthe Truss, Probably Would Not Have Lived to Write This+ To be honest with you, I don't believe I would be here to write this if it had not been for the Cluthe Truss. Can truthfully say I have been wonderfully benefited, and feel as though my rupture is cured. I strongly advise all ruptured people to try the Cluthe Truss and be convinced. E. E. JOHNSON, R.F.D. No. 2, Haviland, Kansas. October 3, 1911. +Prominent Saratoga, N.Y., Man Cured of Long-Standing Rupture in One Year+ My case was a severe scrotal one, with ruptures on both the right and left sides. It had been in peril of my life for a number of years, receiving no relief from different trusses which I tried. Fortunately I learned of yours, and now after only a year's use, I am completely cured. B. F. JUDSON, (Veteran of Civil War. Ex-postmaster of Saratoga Springs for 18 years. Publisher and proprietor of Daily "Saratogan" for 25 years.) Saratoga Springs, N.Y. October 6, 1911. +Was a Godsend to Him+ The Cluthe Truss I purchased of you was a godsend to me. I found that it did all that you led me to believe it would do. HERMAN LOHLEY, 4111 Humboldt Ave., Chicago, Ill. September 29, 1911. +Cured in Eight Months+ I can truthfully say I am a well man. You may, with the greatest of pleasure, use my testimony it if will help anyone who is afflicted with rupture, and I will do all in my power to induce others that I know and suffer as I did before I was wise enough to try the Cluthe Truss. May God crown you in all your efforts, and give you great success. F. DUDLEY KNAPP, Housatonic, Mass. November 3, 1911. +Cured His Rupture and also His Friends+ In justice to you I will state that I am permanently cured, by use of your truss, and have not been very quiet in recommending your treatment to others similarly afflicted. A neighbor sent for your truss at my solicitation, and he tells me that he, too, is completely cured. We fully appreciate the great good you are doing. A. W. KEDDIE, Quincy, Cal. October 4, 1911. +Nine Months of Cluthe Truss Comfort Cures This Man+ I must thank you for all the good your truss has done me. Since wearing your truss, I have felt like a different man. I have worn it only nine months, and can truthfully say that I am completely cured of my rupture. FREDERICK L. KLINGLER, Rexburg, Idaho. October 13, 1911. +This Missouri Doctor Cured+ I believe my rupture is cured, although I have worn the Cluthe Truss only about three or four months. I have not lost a day out of the saddle since I received the truss. Before, I could only walk my horse with other trusses I wore, but with my Cluthe I could ride just as well as I could before I was ruptured. Yours is so perfectly easy one does not know one has it on. I will be seventy-three years old next month. I cannot speak too highly of your truss. I don't see how it could be improved upon. From my own personal experience, I would say that anyone ruptured who follows your simple directions, is on a quick road to complete recovery the moment he wears a Cluthe Truss. DR. D. J. McCONNAHA, New Bloomfield, Mo. November 10, 1911. +This Oregon Man Cured+ I am almost sure I am cured. Your truss is so easy that I feel lonesome lost unless I have it on. Consequently, I wear it most of the time. I tried five different kinds before I was fortunate enough to hear of the Cluthe Truss. I am doing a little missionary work for you all the time in appreciation of the great good your truss did for me. C. E. MAXSON, Harrisburg, Ore. October 10, 1911. +Thinks Cluthe Cure a Great Thing+ I think I am permanently cured. I cannot recommend your truss too strongly to anyone I know who has a rupture. Some of my neighbors have already sent to you for advice and treatment, and others will do so soon. I consider the Cluthe cure a great thing. S. L. LEE, Quincy, Cal. November 21, 1911. +Quick Cure by Cluthe Truss+ I have had my Cluthe Truss only two months, and believe I am cured right up. I can honestly say that your truss has done for me what no other truss ever did, that is hold the rupture up, and to think that it even cured me. Of course I shall continue to wear the truss some time, although no rupture shows when I leave the truss off. I believe your truss is sure to cure most people with rupture, if they would only buy it. JAMES T. McDONALD, 45 St. Patrick St., Goderich, Ontario, Can. November 16, 1911. +Has Not Had to Wear Any Truss for Years+ I am sure my rupture, which was cured by a Cluthe Truss, will never come out again, now after so long. I have been without pain for years. I have gladly recommended the Cluthe Truss at all times, for I know what wonders your truss did in my case. JOHN M. McDONALD, 30 Union St., Dominion No. 1, N.S., Can. October 19, 1911. +Tried All Kinds, but Only the Cluthe Cured+ I purchased your truss about eighteen months ago. It cured my rupture. Previously I had tried all kinds of trusses, but it remained for the Cluthe Truss to cure me. It is the only one worthy of the name. JOHN McNAMARA, 861 West Main St., Greenfield, Ind. October 18, 1911. +This British Columbian Man Cured+ I can go about without my truss, but I wear it at my work, as I feel safer with it on. I find it most comfortable. THOMAS MILBURN, Victoria, B.C., Can. October 17, 1911. +Cured for Good+ I cannot speak too highly of the Cluthe Truss. It has stood by me constantly while before I got your truss I could get nothing that would give me any relief. Yours has done the work, for I believe that the rupture is entirely healed. FRANK MIXER, R.F.D. No. 1, Box 12, Whittier, Cal. October 13, 1911. +Practically Cured in Five Months+ Your truss has done me more good in five months than all the others I wore before I got the Cluthe Truss. I put it on the 20th of May, and from that time to this the rupture never showed. I now know that my rupture is completely cured, because I have not worn the truss for weeks, and feel no weakness on account of not wearing it. Let any ruptured man know what I write here, hoping the Giver of Goodwill will always smile on me. J. L. MOSS, Atwood, Ala. October 13, 1911. +Cluthe Truss Hangs in Closet While He Does His Work, Cured+ I can truthfully say I am cured by the use of your truss. I believe it is the best truss ever invented by man. It did for me just what you said it would. My truss is now hanging up in a closet in my house, and I don't have to use it at all. Anyone can write to me if they don't believe what you say. So give this to the suffering people of this land, for why should it not do for thousands of others what it has done for me? J. W. MITCHELL, Olympus, Texas. October 13, 1911. +Ruptured Ten Years; Cured by Cluthe Truss+ I had suffered for ten years, and will admit that when I purchased your truss I did not expect it to cure me, for the reason that I had been disappointed by so many different makes or makers. I shall gladly recommend the Cluthe Truss to anyone that I shall come in contact with, who is suffering with a rupture. E. SCOTT MORGAN, 5619 Georgia Ave., Washington, D.C. October 6, 1911. +Doctor Says in Six Months Will Be Entirely Cured+ My ruptures are so now that they do not come down without the truss, but my doctor says to wear it for six months longer, and then I will be able to go without the truss altogether. I have only had the Cluthe Truss four months. MRS. J. G. MILLER, 1104 7th Ave., Seattle, Wash. September 27, 1911. +Cluthe Truss Makes Him a Different Man+ I do not know how to express my gratitude to you. Money could not buy my Cluthe Truss from me. My health is so much better and I feel so different than I used to before I purchased your truss. I was always afraid to go ahead and do any work, fearful of the consequences, but now I never think of it, for I feel absolutely safe. I am confident that if I knew about your truss sooner than I did, I would be a well man to-day. CHARLES McDONALD, Sheridan, Ore. October 2, 1911. +Tried the Whole Category of Trusses, and Finds Only Cluthe Makes Good+ It gives me much pleasure to state the truth about the Cluthe Truss. I found it the best truss I ever tried, for I have tried about the whole category of trusses, and no truss ever did me any real good until I purchased this one, which I have worn for about four months with comfort. I have not had a moment of trouble with my rupture since putting the Cluthe Truss on. I believe myself to be cured. I have worked hard all the time, doing work that I could not have done before I had my Cluthe Truss. HUDSON MILLS, Hooser, Kan. October 3, 1911. +Almost Cured in Three Months+ I am almost cured already, although I have worn the truss only three months. My rupture has not been out since I put the truss on. It certainly was a God-send to me when I got your truss, and I cannot recommend it too highly. A. L. MYERS, Ilwaco, Wash. September 25, 1911. +Took Six Months to Cure This Rupture+ I am glad to state that after wearing your truss since last February I feel I am cured to stay cured. As my work requires heavy lifting, I still use the truss while working, but at all other times I never have it on. I have not had to wear it for the last three months. The truss is just as good as the day I bought it. O. NORBECK, 1079 17th Ave., Minneapolis, Minn. October 25, 1911. +Cured in Five Months+ I purchased my Cluthe Truss last February, wore it five months, and have not had to wear any truss since. From the first day I put it on to this present day, the rupture has never been out or bothered me in any way, and I have done lifting and all kinds of heavy work all this time. So I have reason to feel sure I am cured. CHARLES T. NASS, Robinsons Corner, N.S., Can. September 30, 1911. +Cluthe Truss Does What Physician Advises Only Surgical Operation Could Do+ I have been so greatly benefited by your truss that I feel myself practically cured. I suffered sixteen years and tried many different trusses during that time. Physicians advised me to go through an operation. Your truss gave me relief the first day. I cannot speak too highly of if. I cannot recommend it too strongly to anyone afflicted. ZEPHANIAH PARKS, R.F.D. No. 1, Saco, Maine. October 4, 1911. +Never Saw Rupture Since Wearing Cluthe Truss+ My rupture has never come out since I got the truss, and I have often left my truss off all day without any signs of the rupture showing. Before I got the Cluthe Truss I suffered all the time, but yours gave me comfort from the moment I tried it. JAMES NAYLOR, E. Arrow Park, B.C., Can. October 4, 1911. +Cured in Less than 4 Months+ I have had your truss less than four months, and have been able to go without it for a week at a time, without the rupture coming down. So I think I am about cured, with many thanks to you. W. H. NEAL, 136 Race Path St., Fayetteville, N.C. September 25, 1911. +Man Seventy-two Years Old Cured+ I take pleasure in aiding all my friends who are ruptured. I am entirely cured, and do not need to wear a truss now. I am 72 years old. One man to whom I recommended the Cluthe Truss says he would not take $150 and be without his truss, if he could not get another. Use my recommendation any time. J. A. PRICE, 906 Cruise St., Corinth, Miss. October 20, 1911. +This Case of Double Rupture Cured+ Am writing you to let you know what your truss has done for me. My ruptures are both healed up perfectly sound. They do not bother me in the least. I cannot say enough for the Cluthe Truss. You have my permission to use this letter, and I would be glad to make affidavit to it, if you wished. HIRAM PEIRCE, Watervliet, Mich. September 23, 1911. +Another of the Thousands of Kansans Cured by Cluthe Truss+ I go weeks at a time without the truss, but when I am at heavy work I keep it on as a wise precaution. I would not take many times what it cost for it. I am more than satisfied with your treatment of my case. W. E. CROWL, Riley, Kansas November 18, 1911. +Entirely Cured+ I wish to say that I consider myself most fortunate in having heard of the Cluthe Truss. It has entirely cured me of my rupture. ERNEST RUEMMELIN, Ashton, Rhode Island. October 23, 1911. +Never Spent any Money in His Life that Did Him So Much Good+ I was ruptured for six years and never got anything that did me any good in that time till I got this truss from you. I tried everything I heard of before I got my Cluthe Truss. I am now about well, but I still wear the truss when doing heavy work. I never spent any money in my life that did me so much good. CHARLES RILEY, Northspur, Cal. October 10, 1911. +Saved from an Operation, Costing at Least $300, by the Cluthe Truss+ I am getting along finely. I have only worn the truss a few weeks and would not expect a cure of my case so soon. I work about fourteen hours a day, and am on my feet all day long. I never have the least trouble with the truss, and would not sell it for any money. It saved me from an operation costing at least $300. I wish you all the success you deserve. JACK ROTH, Le Mars, Iowa. September 29, 1911. +Ohio Minister Cured+ I still wear my Cluthe Truss, though I am cured, as it gives me no uneasiness or discomfort. REV. A. N. SMITH, Van Buren, Ohio. October 19, 1911. +Prominent Arkansas Man Quickly Cured+ It is only in justice to you, and a great pleasure to me that now after wearing your truss for 90 days, to say that I find my rupture back in place and that it does not come down without the truss. However, I have thought it best to wear it for a while longer, believing that my case, a double rupture of 50 years standing, is practically cured. I am 67 years of age, and during that time I have tried over 25 different trusses and treatments for rupture. A. H. SOEKLAND, Ex-Postmaster of Stuttgart, Ark., and Past Department Commander G.A.R. of Arkansas, Stuttgart, Ark. October 13, 1911. +Only Real Device for Rupture Made in the World+ I wish to state a few facts concerning your truss. It is the only real device for rupture made in the world. It cured me. I don't know what I would have done if I had not heard of the Cluthe Truss. GEORGE STOREY, 17 West 4th St., Jamestown, N.Y. November 9, 1911. +Considers Cluthe Truss a Wonder+ The truss I purchased from you about six months ago is a wonder. It has me about cured. You can use my name whenever and wherever you wish, and I will help any person that suffers with rupture anywhere in the city of Chicago or any other city, that writes me to verify this statement. CHARLES C. SCHMIDT, 2275 Archer Ave., Chicago, Ill. October 3, 1911. +Cured In Seven Months While Indulging in Athletic Sports+ I had tried several so-called trusses with poor results up to last May, when you fitted me, and I can positively state that from that day my rupture has not been down since. I indulge in athletic sports, in swimming and bathing and wore your truss in the water with no inconvenience whatever. I feel confident that I am now entirely cured of my rupture, and write this hoping that some afflicted brothers may take advantage of your grand invention. You may use the above for recommendation if you wish. FRANK A. PLUNKETT, 25 Water St., New York City. +Absolutely Cured by the Cluthe Truss+ About August, 1909, I began using your truss for rupture. With it life was not such a misery as all my other trusses had made it. Some months thereafter I took the truss off and found I was completely cured. And herewith greetings and heartfelt thanks, for I know your members to be great benefactors to suffering humanity. Before I bought my Cluthe truss I was examined by two "doctors." One would cure me with the knife for $200 and $25 per week while in hospital, and the other, by injection, for $150, and he would also use some form of Spring truss. You are at liberty to use these few words any way you wish. D. A. ROSS, R.F.D. No. 3, Oklahoma City, Okla. +Doctor Who Was to Operate Calls It Perfect Cure by Cluthe Truss+ I am perfectly cured by wearing one of your trusses. My rupture was as large as a goose egg, and was out all of the time. I put your truss on and kept it on for one hundred days, and when I took it off the rupture was all healed up and cured. The doctor who was going to operate on me called it a permanent cure. CHARLES E. ROBERTS, 720 Calvert St., Rome, N.Y. October 6, 1911. +Proof of Permanency of Cure by Cluthe Truss+ Please send me an order blank for a friend. It may interest you and others to know that I purchased a truss of you many years ago, which cured me. L. E. DRAKE, Bellevue, Alta, Canada. +Cured by Cluthe Truss in 6 Months+ Your Truss is all you claim for it. I have had the truss about six months and never had any symptom of trouble since then. I am now cured and will only be too glad for you to refer anyone to me for any reference you want. I tried many other trusses with no relief. Those afflicted should not delay in getting your truss. G. P. LA FOLLETTE, 289 Edith Ave., Memphis, Tenn. +Blacksmith Cured While Doing His Work+ I bought one of your trusses about eight months ago and am more than pleased with results. I have worked hard-- even at horseshoeing-- every day since I put the truss on, but in spite of all that it cured me of my rupture. PHILIP POGREBA, Delano, Minn. +Cluthe Truss Cured This Californian 76 Years Old+ I am glad to have the opportunity of letting the public know of the benefit I received from the truss purchased from you. It is all you claim for it, for my left rupture is now cured and the one on the right side almost well. I am past 76 years old but I felt all of ten years younger from the day I commenced using your wonderful truss. I shall be indeed glad to impart to those who suffer as I did, any information I can give regarding the Cluthe Truss. W. L. NOTLEY, 63 Pearl St., Santa Cruz, Calif. +Now Over 81 Years Old-- Was Cured by Cluthe Truss+ My rupture is all well and the cure is complete, but I keep the truss on day and night because I am over 81 years old and might take a fit of sneezing. With many thanks for your kindness. G. A. P. BRYANT, R.F.D. No. 1, Smyrna Mills, Maine. +This Chicagoan Cured in 3 Months+ After I had worn your truss three months, I noticed that the rupture did not appear as formerly on retiring at night. An instance-- my cat had a fit one night, I jumped out of bed very hurriedly, grabbed the cat, rushed down two flights of stairs and threw the cat out on the porch. When I returned to my room I thought of the truss, not having thought to put it on before going downstairs-- was overjoyed to find that there was no sign of the rupture; this was several months ago and there has been no return of the rupture since. Would be pleased to recommend the Cluthe Truss at any time. ROBERT STEWART, Western Bank Note Co., 20th street and Indiana avenue, Chicago, Ill. +Cured by Cluthe Truss While Sawing and Chopping Wood+ My rupture has never bothered me since I started to wear the Cluthe Truss. I found it to stay in place just as you recommended it, while at hard work such as sawing and chopping wood, digging and carpenter work. I thank you for the great good and the cure it has effected for me. ENOS MUNRO, Winchester Springs, Ont., Canada. +Cured-- and Cannot Recommend It Too Highly+ I was more than satisfied with my Cluthe Truss. It cured me of my rupture and cannot recommend it too highly. DANIEL BOWEN, 63 N. 9th W., Salt Lake City, Utah. +This Scrotal Rupture Cured+ The truss I bought of you less than a year ago has been a wonderful success. I am now entirely cured of my scrotal rupture. ISAAC SHIDELER, 316 Market St., Logansport, Ind. +Has Worn Cluthe Truss only 6 Weeks and Fast Getting Well+ I have worn the Cluthe Truss six weeks and am fast getting well-- can't see or find anything of my rupture now-- but shall wear truss longer. The elastic truss that I used to wear got so wet on the body that I had to tighten it up to get it to hold-- only to have it fail me later in the day. Mr. Fitzgerald has also been greatly benefited by his truss he got from you. ROLAND T. ELLIS, 141 Albion St., Somerville, Mass. +No More Sign of a Rupture+ I am now well and don't see any signs of being ruptured-- thanks to the Cluthe Truss. GEORGE DAILEY, R.F.D. No. 1 Osco, Ill. +Cured While Doing Heavy Work+ I felt like a different man the very first week I wore my Cluthe Truss, and it has done me so much good that I can safely leave it off entirely. However, I take no chances, and being so comfortable and easy, I put it on when I have extra heavy lifting to do in the course of my heavy work. I have spoken to many of my friends about the wonderful Cluthe Truss. JOHN HOLDORF, 119 N. Ann St., Baltimore, Md. +From One Who Has Tried Them All+ I write to let you know that I cheerfully recommend the Cluthe Truss for rupture. It does all you claim for it. I had been ruptured for many years and tried all kinds of trusses and rupture cures but found no relief until I used yours. JOHN COUGHLIN, National Soldiers' Home, Milwaukee, Wis. +Thanks God Daily for the Cluthe Truss+ This is simply to inform you that I must every day when I put your truss on thank God for having found something which is not a fraud but a blessing to all ruptured people. The Cluthe Truss enables me to take my place among men, either in running, jumping or other hard work. It is safe and comfortable and I would not be without it, knowing the Cluthe Truss existed. JAMES CHAMBERS, Burquitlam, B.C., Canada. +What This Kansan Says+ I will say your truss has helped me very much. Believe I am now cured for sure as the rupture does not come out now when the truss is off. It is the best thing I ever tried. Will tell everyone suffering from rupture to try this truss. J. C. S.---- of my town sent for one through me. You can use my name. WILLIAM STERLING, Herington, Kans. +Recommends Cluthe Truss to All+ I think it my duty to notify you that the Cluthe Truss you made for me was indeed a great success. My rupture has disappeared and I am so far cured. I certainly recommend the Cluthe Truss to all in need of relief from rupture. JACOB STRAUSS, 215 Cooper Avenue, Lockland, Ohio. +This Philadelphian Cured in Less Than 8 Months+ It gives me great pleasure to write you a few words of commendation in reference to the truss I purchased from you in March, 1910. I, at first, doubted its full value as I thought my rupture was incurable, but subsequent results have proved my error. Ever since my birth I have endured the pains and torture of a rupture until I started to wear your truss, which was nearly eight months ago. I am now entirely cured of my rupture-- thanks to the Cluthe Truss. Gentlemen, I thank you very much for your able device and assistance, as you have made me feel like a new man after all these years of misery. You may use anything I have written, as I like to encourage a good deed. LAWRENCE V. RASCH, 2018 S. 64th St., Philadelphia, Pa. +Read What This Massachusetts Physician Says+ I am much interested in making known the excellence of the Cluthe Truss, for I have confidence in its curative process. You can refer to me any time you desire, not only as to the worth of your truss but also as to the fair dealing you manifest toward your patients. DR. G. J. PIERCE, 1 Crown St., Worcester, Mass. +Ruptured 30 Years, Believes He is Now Cured+ I have been ruptured for 30 years and have worn a good many kinds of trusses and I never got one that did not nearly kill me at times. My doctor has been trying for years to have me undergo an operation, and I nearly made up my mind to have an operation when I saw your advertisement in the Chicago Tribune. I decided to try once more to get a truss, and after thinking about it and putting it off for six months I finally purchased one of your trusses three months ago. If I had only sent for one when I first started I would not need to wear a truss now. My rupture was a large one and since wearing your truss the rupture has never been out. I can now stand on my feet without the truss on and rupture does not show-- the opening seems to be closed. I feel so grateful for the relief that I cannot help but thank you and any time you wish to have anyone call on me I will gladly recommend you. W. H. BRUCE, 204 East 54th St., Chicago, Ill. +Proof of Permanency of Cure by Cluthe Truss Years Ago+ The truss purchased of you years ago gave me permanent relief and cure. While I was always skeptical as to a permanent cure of rupture by means of a truss the fact remains that after following your advice and instruction, I have been going about without a truss, doing all kinds of work same as I did prior to becoming ruptured. I cheerfully recommend your truss to one and all afflicted with rupture. Only the patient himself knows from experience how he has to suffer. Publish this letter if you so desire. J. LEINBERGER, Route No. 1, Souderton, Pa. +Now Freed of His Rupture Trouble+ I was in awful misery before I ordered a Cluthe Truss and as soon as I put it on I felt like a new man. I can now leave truss off without detecting the least sign or feeling of the rupture. I most highly recommend the Cluthe Truss to any one who is ruptured and wish to give you my best thanks for what it has done for me. ADAM DEHSOY, South Milwaukee, Wis. +Did Not Believe Cluthe Truss Would Cure, Now Happily Disappointed+ Over a year ago I bought a Cluthe Truss but had no belief that it would cure my rupture. I have been, however, happily disappointed and am now glad to inform you and everyone suffering from rupture, that the Cluthe Truss did cure my rupture entirely. Thanks to you. GEO. L. PRENTICE, 29 Mechanic St., Putnam, Conn. +For 47 Years Suffered with Wrong Trusses, Cluthe Truss Proved Its Worth in This Case+ I was ruptured in the spring of 1863; for 47 years I bought and wore all kinds of trusses and none ever held the rupture. One year ago I bought the Cluthe Truss; it holds the rupture securely, I have better health, can now do any kind of work on the farm and forget actually that I wear a truss; I have no dread now of strangulation and am thankful I saw your adv., sent for your book and bought the one truss that by experience proves that it holds the rupture at all times. I am now in my 85th year and happy with the Cluthe Truss. JAMES S. MC CLURKAN, R.F.D. No. 1, Box 63, Murrysville, Pa. +Cured by Cluthe Truss in 5 Months After Suffering 49 Years+ I have worn your truss since August and in the following January-- merely by chance-- I took off the truss. To my surprise I could not see any rupture nor feel any opening-- nor after coughing, the spot is firm and no protrusion. While as a member of Co. F, 46th N.Y. Vol. Inf., during the bombardment of Fort Pulasky, I ruptured myself, and ever since-- after 49 years (April, 1862), I have tried many trusses with no results of any benefit until I tried yours. I gladly give the Cluthe Truss my strongest recommendation on what it has done for me. C. G. RUSSE, Phoebus, Va. +Wore Other Trusses 4 Years without Benefit, Cluthe Truss Cured in 3 Months+ I take great pleasure in adding my name to your list of cured patients. I wore the Cluthe Truss but 3 months and am now entirely cured. I wore other appliances for four years without the slightest benefit. With best wishes and many thanks and assuring you you may use my name in any way you wish. W. E. HENDERSON, Independence, La. +Perfectly Well After One Year's Use of Cluthe Truss+ Kindly mention my name in your book of cured patients, as I have worn the Cluthe Truss but one year and am now perfectly well and trying to get others to buy Cluthe Trusses. P. L. PINARD, Las Vegas, New Mexico. +Wonderful Cure for His Double Rupture+ Many years ago I discarded the Cluthe Truss as it cured me of my 2 ruptures. I now look upon this cure as permanent, and wonderful, as I was past the middle of life and suffered torture from other trusses before ordering the Cluthe Truss. I consider it my duty to recommend the Cluthe Truss to all people afflicted with ruptures. W. B. FISH (Pres.), Bullock Mfg. Associates, Springfield, Mass. +Another Thankful Man Cured by the Cluthe Truss+ I was cured of my rupture trouble by the Cluthe Truss and cannot speak too highly of the benefits I received from it. I shall spread your wonderful work abroad to all in the condition I was in. FRANK KENNEDY, Ingram Port (Halifax Co.), Nova Scotia, Canada. +Satisfaction from the First+ Some time ago I purchased the Cluthe Truss, which has given excellent satisfaction from the time I used it. It has cured my right side rupture entirely and the left side is also nearly cured. MOSES KELLER, Fleetwood, Penna. +A New Man Since Wearing the Cluthe Truss+ It will soon he 2 years since I purchased my Cluthe Truss. I certainly have been a new man ever since I put it on. I have left it off and felt no bad effects from doing so. I am now cured. A. M. ROGERS, 120 Henry St., Binghamton, N.Y. +Cluthe Truss Cures Absolutely+ I am absolutely cured of my rupture by the Cluthe Truss. I consider your truss the best device ever made for rupture. J. F. WOEHR, 167 Perry Ave., Maspeth, Long Island, N.Y. +Relief After 23 Years of Torment. 84 Years Old+ After 23 years of torment with different appliances I put on the Cluthe Truss as soon as received and have not taken it off night or day since and have no reminder of it being on. It was a blessed day for me when I received it. I am 84 years old. JEREMIAH GOVE, Griswoldville, Ga. +More Comfort in One Month Than Before in Years+ After more than a month's test of the Cluthe Truss, I wish to inform you how well pleased I am with it. It holds me perfectly. I have taken more comfort since wearing the Cluthe Truss than I had for years. PRYCE W. BAILEY (Postmaster), Seneca Falls, N.Y. +Would Not Take $500 for His Cluthe Truss+ My father, John Brierley, wishes me to write you that he would not sell his Cluthe Truss for $500 if he were unable to procure another like it. W. P. BRIERLEY, M.D., 228 Central Ave., Albany, N.Y. +His Rupture Has Healed+ I have been wearing the Cluthe Truss several months and my rupture has not come down in that time. I took the truss off 8 days ago and have not noticed the first sign of a rupture and I believe it is all healed up. Thanks for the greatest of all trusses, the leader of them all. J. J. CONLON (Box 38), Spring Valley, N.Y. +Cluthe Truss Made New Man of Him+ Having used your Cluthe Truss for 3 months, I feel now that I can highly recommend it. It has made a new man of me and my rupture has never been out since putting the truss on. CHAS. W. HOWELL, R.F.D. No. 3, Trenton, N.J. +Cured His Son+ A short time ago I bought a Cluthe Truss for my son, which Truss I am thankful to say has cured his rupture entirely. He is a very strong boy continually jumping and tumbling around and still we can see no sign of the Rupture. You can refer anyone you wish to me. A. A. DAVIS, 2844 38th Place, Chicago, Ill. +Ruptured 13 Years, Cured by Cluthe Truss+ I suffered torture with a rupture for 13 years. Then I got the Cluthe Truss, which cured me in a short time. Your truss is more than you say it is. I can get a doctor to back all I say for the Cluthe Truss. JOHN T. IBEY (Box 60), Meyersburg, Ont., Canada. +Another Man Cured+ Some time ago I bought a Cluthe Truss and I write to tell you that it has cured my rupture. FRANK E. BARNES, Philipsburg, Mont. +Can Recommend Cluthe Truss to All+ I can recommend the Cluthe Truss to all persons suffering from rupture. I surely have been benefited by the Cluthe Truss very much in the short time I have been wearing it. CHAS. F. WECKER, 410 W. Princess St., York, Pa. +Wants World to Know He was Cured+ I was cured by the Cluthe Truss after suffering from a rupture for 20 years and I want the world to know of my cure. I have not had my Cluthe Truss on in 8 months and I can see no sign of my rupture. MILTON M. OWENS, Oak Hill, Fla. +Another Cure and Another Thankful Man+ I am very thankful to Mr. Chas. Cluthe, for he was the first man that ever told me where my rupture was. Two doctors wanted to operate on me and were about to get me into a hospital when I heard of the Cluthe Truss and bought it and it has cured me of my rupture. Both doctors were about 6 inches out of the way of where Mr. Cluthe told me my rupture really was. FRED A. WOOD, 269 Fayette St., Hammond, Ind. +Sends His Patients to Us+ I have sent my patients to you with perfect satisfaction, knowing you have an excellent truss, the Cluthe Truss. A. EUGENE AUSTIN, M.D., 616 Madison Ave., New York City. +Now Well and Sound-- Goes Bowling+ Last month I took off your Truss as I am cured and I now go down to the bowling alley and often spend an hour and a half bowling and I do not feel anything and am satisfied that I am now cured. I will consider it a pleasure to recommend the Cluthe Truss. H. W. ERWIN, 190 W. Brookline St., Boston, Mass. +This New York City Man Completely Cured in Less Than a Year+ I found such good results from the use of the Cluthe Truss that I only had to wear it less than a year when I was completely cured. I have since been as well as ever I have been in my life. ANDREW RUFF, 661 Ninth Ave., New York City. December 22, 1911. +Could Hardly Walk. Now Rid of All Pain+ Words cannot praise the Cluthe Truss highly enough. After suffering 9 years I purchased a Cluthe Truss and it has rid me of all pain. Before wearing your truss I was unable to walk half a mile. But one morning lately I walked 8 miles and if my feet did not give way I think I would be walking yet. I have no pain now and perform all my household duties, as I could not before wearing the Cluthe Truss, because I had such pain from my rupture. I owe much to the Cluthe Truss. It saved me from the knife. MRS. A. H. LAMEY, 60 Greig St., Rochester, N.Y. +Man of 79 Has Nothing But Good to Say+ I have nothing but good to say of the Cluthe Truss for what it has done for me, a man 79 years of age. D. F. WOODWARD, Pine Island, Minn. +Wouldn't Take $100+ I wouldn't take $100 for my Cluthe Truss. Success to the Cluthe Truss. R. L. AUTER, Vicksburg, Miss. +Ruptured 20 Years; Cluthe Truss Holds Perfectly+ Truss received and am well pleased with it. It is a perfect fit and holds my rupture perfectly. The Cluthe Truss is the first one to hold my rupture in 20 years. F. W. JONES, Enterprise, Okla. +Thanks to Cluthe Truss Can Now Climb Trees+ The Cluthe Truss is the only one worthy of the name of truss. It was the best investment I ever made. I suffered untold agony with other appliances, but the Cluthe has been a pleasure to wear. I can now climb trees like a squirrel. Thanks to the Cluthe Truss. WM. LEROY GARRIGUS, Waterbury, Conn. +Says Cluthe Truss is the Best on the Market+ Truss received this P.M. Everything is more than satisfactory. You certainly have the best truss on the market. If I can say a good word for you I shall be more than pleased to do so. ABEL HALEY, Wolfeboro, N.H. +Grateful for the Cure Effected by the Cluthe Truss+ I have not worn my Cluthe Truss in 6 months as my rupture is entirely cured, and I cannot find words to express my gratitude to you and your wonderful truss. It is without doubt the best truss made and I can highly recommend it. A. H. EGBERT, 74 Alexander St., Newark, N.J. +Physicians Say Best Truss They Ever Saw+ I have worn your Cluthe Truss for a month and am free to say it is the only Truss that I ever found perfectly satisfactory. I have worn trusses for 51 years and spent hundreds of dollars; all these were failures. I have shown the truss when on me to several physicians and they all say it is the best they ever saw. J. MABBOTT BROWN (Supt.), Madison Fire Agents' Asso., 35 Tenney Block, Madison, Wis. +Ruptured 20 Years; Cured in 5 Months+ For the benefit of those who are in the dark about Trusses and who are suffering unnecessarily, I wish to state, without solicitation on your part, that after spending over $200 for all kinds of trusses for over 20 years, I purchased a Cluthe Truss in March, 1908. Five months later I took off the Truss and have not worn any since. My rupture is cured and I am to-day as strong and well as the healthiest man. I might add that I did not take your promises seriously when I purchased the Truss, but I have changed my mind since and I hold you now in the highest respect and believe you fill a long-felt want for the suffering thousands. Anyone can communicate with me who doubts the truth of this assertion. HUGH A. MACKENZIE, North Lake Ainslie (Inverness Co.), C.B., N.S., Canada. +Clergyman Tells How He was Cured+ I am only too glad to add my word of commendation as to the value of the Cluthe Truss. I had used a number of others with no permanent good. You cannot say too much in reference to the Cluthe Truss. It does all you claim for it. It cured my rupture. REV. DR. GEO. M. HAMLEN, Vineyard Haven, Mass. +Cured by Cluthe Truss; Now Does Heavy Lifting+ I write to tell you that I was very much benefited by the Cluthe Truss. I have not worn it in 2 months and have not felt the rupture at all. I work in a feed store and have to do very heavy lifting. JAS. A. CRAWFORD, 109 North St., Middletown, N.Y. +Says Doctors are Enthusiastic+ The Cluthe Truss has given me wonderful satisfaction. I have shown it to quite a number of people and doctors and they all think it a fine truss. My rupture is now entirely cured. JOHN J. CROAKE, Culebra, Canal Zone, Panama. +After Trying All Kinds; Cured in a Few Months+ After trying all kinds of trusses which did more harm than good, I purchased a Cluthe Truss about 5 years ago and after wearing it a few months have not seen or felt the rupture. I am entirely cured and can recommend the Cluthe Truss to anybody suffering with a rupture. FRED KROESCH, JR., 2228 John St., Ft. Wayne, Ind. +Cluthe Truss Brings Long Denied Comfort+ Your truss received. A perfect fit. Have put it through a severe test the past month and I am pleased to state that it has given me a long-denied comfort, is satisfactory in every way and a master of my rupture, for which accept my thanks and lasting gratitude. I deem it my duty to recommend the Cluthe Truss whenever I can. CHAS. H. MEADS, Ellicott City, Md. +Permanently Cured 10 Years Ago+ I purchased a Cluthe Truss from you about 10 years ago and after wearing it one year I found it cured me and this cure has been a permanent one. R. H. NELSON, Irvona, Pa. +Cannot Speak Highly Enough for the Cluthe Truss+ About 8 or 10 months ago I purchased a Cluthe Truss which I have worn with the greatest success. About a week ago I left Truss off and find that the Rupture does not show; neither have I felt it and I think I am cured. However, I shall put Truss on and wear it when I have hard work to do as a special precaution. I cannot speak highly enough for your Truss. R. E. LOWDER, Cooleemee, N.C. +Medical Student Cured by Cluthe Truss+ I am glad to say that after wearing the CLUTHE TRUSS I laid it aside over a year ago and have not needed it or any other since. I am taking up the medical profession now and if I can be of any service to you at any time in future I will be glad to be of such service. ARTHUR L. BLACK, M.C. of S.C., Charleston, S.C. +Freed This Man of His Rupture Trouble+ I take pleasure in giving you my full consent to make public my testimony regarding the benefit derived from your scientific Truss. If you meet with any "Doubting Thomas," send them to me. I will be pleased to tell them what it has done for me. T. B. GALLAGHER, 167 W. 129th St., New York City. +Saved Him from an Operation+ I can safely recommend the Cluthe Truss as the only safe alleviator of the terrible sufferings of those unfortunate sufferers from rupture. It was the Cluthe Truss that saved me from an operation. My very highest commendations for the best truss-- the CLUTHE TRUSS. E. F. GRIFFITH, 127 31st St., Newport News, Va. +Himself Cured by the Cluthe Truss; Sends Order for a Friend+ I take pleasure in handing you herewith Mr. ---- 's order for a Cluthe Truss together with remittance, which order please acknowledge. Mr. ---- is an employee in our office and being familiar with my rupture troubles became convinced that as your Truss cured my rupture it ought to do the same for him. Hence his order enclosed. C. A. McLANE, c/o Laredo Water Co., Laredo, Texas. +Cured, But so Comfortable Would Feel Lost Without Truss+ I believe I am absolutely cured by the Cluthe Truss, but I still hang onto it; would feel lost without it. I should consider it a pleasure to recommend the Cluthe Truss to any doubting or suffering ones for I KNOW what it is. CHAS. M. BACHMAN, 603 E. Fayette St., Syracuse, N.Y. +Utica Man Thinks of Us as Old Friend+ The Cluthe Truss has given me such a wonderful cure that I think of the Cluthe Co. as an old friend. J. C. BIGELOW, Sr. (Florist), 2 Columbia St., Utica, N.Y. +Says Cluthe Truss is Finest on Earth+ I am more than pleased to acknowledge receipt of the Cluthe Truss, which arrived last Saturday, and to say that the wearer reports it the finest on earth. You are at liberty to refer any and all to me. H. C. KING (Broker), 22 Fifth Ave., Chicago, Ill. +Cured by the Cluthe Truss+ I am glad to let you know my rupture is cured by the use of the Cluthe Truss. F. F. KRALISCHECK, Seymour, Conn. +Cluthe Truss Gives Perfect Satisfaction+ My Cluthe Truss has given perfect satisfaction. The left side rupture is entirely healed and right side much better. Have taken a great deal of pleasure with it. GEO. A. HANSON (Box 1154), Bath, Me. +This Yonkers, N.Y., Man Cured+ I recommend the Cluthe Truss to everybody who needs one, as it cured my rupture. M. SAMUELS, 189 Ashburton Ave., Yonkers, N.Y. +Double Rupture Cured in 6 Months+ It is now 6 months since I purchased my Cluthe Truss and I have not seen any sign of my two ruptures since. FRANK VAN WINKLE, 430 Plane St., Newark, N.J. +Couldn't Work Until He Got Cluthe Truss+ You may tell the world that you make the best truss in the world. I have been ruptured 10 years and wore 4 different appliances before the Cluthe Truss and each of the 4 failed. Since wearing the Cluthe Truss my rupture has not been down once, despite the fact that my work is heavy in a saw mill. I could not do a hard day's work until I got the Cluthe Truss. JOHN K. WEST, Broad St., Tallapoosa, Ga. +Says Cluthe Truss Leads All+ I can truthfully say the Cluthe Truss leads all the others. The old-time harnesses are only a torture. During the past 3 weeks I have been wearing the Cluthe Truss and my rupture has not bothered me since. I scarcely can believe I have it on, it is so easy. ARTHUR FOWLER, 80 East St., Clinton, Mass. +Rides Horseback and Runs an Automobile+ During the few months I have been wearing the Cluthe Truss I have done almost everything that would rupture a man or cause a ruptured man agony or to be operated on. I ride horseback and I am now a chauffeur. Ask any man what it means to crank an engine of high compression. This needs an extraordinary truss to hold a bad rupture under such conditions, but the Cluthe Truss does it. I hardly know I have it on. WM. C. WOOD, care G. L. Boissevain, Mt. Kisco, N.Y. +Cured This Boy of a Bad Rupture+ I am more than pleased to say that the Cluthe Truss cured my 10-year-old boy, who was badly ruptured. I thank God for directing me to you. MRS. EMMA HARRIS, 258 W. 44th St., New York City. +Cluthe Truss "One of the Comforts of Life"+ It gives me great pleasure to recommend the Cluthe Truss to my fellow sufferers from rupture. I have a double rupture and since putting on the Cluthe Truss have had that comfortable feeling ever since. I recommend the Cluthe Truss to the ruptured as one of the comforts of life. It was a friend of mine who had derived benefits from the Cluthe Truss who recommended the Cluthe Truss to me. I thank him for so doing, ever since. WHILDEN H. PAINTER, 51 Eldert St., Brooklyn, N.Y. +His Rupture Has Not Appeared for the Last 4 Months+ I am inclined to think I am cured, but hardly wish to say so absolutely, because I still wear my Cluthe Truss when I work, leaving it off now and then when doing no heavy manual labor. My rupture has not appeared for the last 4 months and I begin to feel confident that it will not appear again. DANIEL BALLARD, Millington, Mass. September 26, 1911. +Hasn't Seen Any Signs of Rupture for Three Years+ I have not seen my rupture for over 3 years. The Cluthe Truss is the best I ever had. E. B. SCULL, Dias Creek (Cape May Co.), New Jersey. +Cured His Little Boy After He Had Been Made Worse at a Hospital+ My little boy was 2 years old when I purchased a Cluthe Truss for him. After wearing it 4 months it cured his rupture. He is now past 4 years and has never been troubled since. We took him to a hospital before we got the Cluthe Truss for him, but they only made him worse. We have only praise for the Cluthe Truss. WALTER C. CHATFIELD, 221 E. 29th St., New York City. +Cluthe Truss Worth Its Weight in Gold+ I bought a Cluthe Truss and wore it about 8 months. It cured my rupture, although I am 74 years old and I am now as free as ever I was. The least I can say about the Cluthe Trusses is that they are worth their weight in gold. XAVIER COLON, Clayton, N.Y. +Best Bargain He Ever Made+ I was cured of my rupture by the Cluthe Truss and it was the best bargain I ever made. I no longer wear a support of any kind. ED. SWOPE, Avon, Penna. +Ruptured 12 Years; Cured by the Cluthe Truss+ The Cluthe Truss has cured me of a bad rupture of 12 years' trouble. It is a blessing to every person affected that way. LEE A. HOLDEN, Norwich, N.Y. +Hasn't Needed Truss for Over a Year+ I am glad to say that I have not needed any truss for over a year. The Cluthe Truss cured my rupture. I find that ruptured people are somewhat adverse to telling others of their trouble. That is why they do not hear all they might from their fellow sufferers. I would be only too glad to impart to them the benefits received from the CLUTHE TRUSS. EDWARD FIELD, Wadena, Sask., Canada. +Thanks God for Having Heard of the Cluthe Truss+ You will remember I got a Cluthe Truss 6 months ago. About 4 weeks ago I took it off and I feel I am cured and have seen no sign of rupture. I feel so much better that I thank God I ever sent for your book. You sent a truss just to fit my case and it cured me and I cannot recommend it too highly. C. N. TUTHILL, Jefferson, Oregon. +Clergyman Cured by the Cluthe Truss+ I am happy to say that since I laid away the Cluthe Truss as being cured by it, I have had no occasion to use it. That is now over 2 years ago. Hoping you may be able to do for many others what you have done for me, I am, B. F. MEREDITH (Pastor), Methodist Episcopal Church, Vale, Oregon. +This Woman Cured in 6 Months+ I found the Cluthe Truss everything it was represented to be and cured myself with it in 6 months and in the future will be glad to recommend the Cluthe Truss to everyone I know to be suffering with a rupture. MRS. R. L. CAREY, 4 Woodruff Ave., Binghamton, N.Y. +Cured in 9 Months+ After wearing the Cluthe Truss for 9 months I laid it aside for a season. I had nothing that would hold my Rupture in until I got your Truss. It has been a blessing to me. God bless you and yours. My Rupture has not been out since I laid Truss off, which is over 2 months ago. In future when sending out your pamphlet, add my name to it. It will show my people what the CLUTHE TRUSS has done for me. E. A. HOWELL, Sr., R. No. 7, Box 40, Booneville, Miss. +Now Does Heaviest Work+ I have worn the Cluthe Truss for 18 months and my Rupture has not been down in all that time. When not working I am now able to go without the Truss. But my work in the hay and grain business is very heavy and I wear the truss when lifting those heavy bales to be on the safe side. JOHN K. MATTHEWSON, 528 Washington St., Providence, R.I. +Himself Cured by Cluthe Truss; Recommends It to Others+ Some time ago you furnished me with a Cluthe Truss which cured my rupture. To-day in conversation with a customer who is ruptured I strongly advised your Truss and he asked me to send you his order, which I do. GEORGE W. GILL, Main St., Pincher Creek, Alta, Canada. +Wants Others to Know of Cluthe Truss+ I consider myself cured by the Cluthe Truss and am glad to do all I can to help anyone who is ruptured by recommending your Truss. Hoping to see my name in your book so I can be of help to others, I am, ELMER P. WILDES, 9 West Daine St., Beverly, Mass. +Indian Chief Cured by Cluthe Truss+ I will always recommend the Cluthe Truss as the only one that did me any good. I am sure I am cured, but at present will not stop wearing it and take any chances, as I am riding on horses nearly all the time, and a trotting horse is the worst thing for any truss or rupture. My rupture never came down. Your truss never hurt me. I shall gladly answer all letters when they send me return stamped envelope. CHIEF IODINE, U.S.S., 625 3rd St., San Diego, Cal. October 20, 1911. +With Cluthe Truss on He Can Now Work on His Farm+ I was operated on for my rupture, but that did me no good. I then ordered the Cluthe Truss and it has been a great blessing to me for I can work now and tend to my farm. May God bless you in your good work. JAMES M. TRIPP, Waverly, Penna. +Double Ruptured 12 Years, Cured by Cluthe Truss+ I had been ruptured twelve years and in all that time I never found a truss or treatment that did me any good until I tried yours. Now I go about without any truss, as I am completely cured-- thanks to the Cluthe Truss. S. A. ANDREWS, Elm St., Stratford, Conn. +Enjoys All Kinds of Comfort from Cluthe Truss+ One month ago I bought a Cluthe Truss, believing at the time I was throwing my money away, as I had purchased so many other appliances during the 40 years I have been ruptured and spent hundreds of dollars. But I must say for once my money was well spent. Since I have worn the Cluthe Truss I have enjoyed all sorts of comfort. It has held the rupture perfectly since applied. It is clean and agreeable to wear; in fact, I cannot realize I wear a truss. I will with pleasure explain and show my truss to anyone in this section, doubting the above. ABE STIEWEL, President, Little Rock Trust Co., Little Rock, Ark. +Cluthe Truss Cured Rupture of 45 Years' Standing+ I left my Cluthe Truss off recently, and there was no sign of my rupture coming out. It cured my rupture of 45 years' standing. Wishing you success. JOHN P. FARBER, 279 Portland Ave., Rochester, N.Y. +Ruptured 44 Years; Helped by Cluthe Truss+ I was ruptured on both sides about 45 years ago by jumping from train in a terrible head-on collision. I bought all kinds of trusses and spent considerable money. Then I got a Cluthe Truss and can now do any work in safety. You are a benefactor of mankind. I had to give up my regular work on train before using the Cluthe Truss. C. MYGATT, 83 Hudson St., Port Jervis, N.Y. +Cluthe Truss Cured This Man+ From the time I put the Cluthe Truss on in June until I took it off the following May as cured of my rupture, it never once let go or slipped. You may use my name in any way you please if by so doing you can help others. S. B. CONNELLY, Pioneerville, Idaho. +Now Goes Without a Truss+ My rupture is cured, as I can go about without my truss. It is too much to believe. It is the Cluthe Truss that cured me. J. BUZZELL, Fernandina, Fla. +Cured Scrotal Rupture of 30 Years' Standing+ To-day is the 10th anniversary since you fitted me with the wonderful Cluthe Truss and I feel that I must not let this day pass without letting you know my opinion of it. Since that day 10 years ago my rupture, a very bad scrotal rupture of some 30 years' standing, has not come down from that day to this, and I am permanently cured. I wish I could tell every poor afflicted mortal throughout this land about the Cluthe Truss, and how much suffering and misery it would save them. I wish you and your four noble sons a long and happy life for the great good they have done and are still doing. WM. H. BUSHFIELD, 55 Tuers Ave., Jersey City, N.J. +Cluthe Truss Cured This Boy After Others Failed+ I wish to say that the Cluthe Truss I bought for my boy has cured his rupture. I had four other appliances for him before I got the Cluthe Truss, but it remained for the Cluthe Truss to cure him. EDWARD PETERSON, Penn Ave., Dover, N.J. +Listen to this Man's Heartspoken Thanks for the Cluthe Truss+ After going through all the pain and misery of a left side rupture for 16 long years which got so bad that it nearly cost my life, after wearing all the different Trusses I could buy, none of them any good as I am a locomotive engineer and my work is of the hardest kind, straining and pulling when I have to reverse my engine a thousand times a day, I purchased a Cluthe Truss. I have worn it 10 days and as regards the rupture I have not seen it since I began to wear Truss, which Truss proves a miracle to me. It fits me so comfortably that I really feel like a new man, started out on a new life in a new world with a heart full of joy and gladness. I would if I were near you call on you and your sons who helped to make the Cluthe Truss and shake hands with each of you and give you my heartfelt thanks for the good you have done me. If there is any sufferer who wants to know about the Cluthe Truss let him write to me. S. S. TEASE, 369 Vancouver Ave., Portland, Ore. +This Texas Man Finds Cure in Cluthe Truss+ After suffering many years, I got a Cluthe Truss which cured me of my rupture after wearing it for five months. EDWIN SIPES, Chicota, Texas. October 17, 1911. +Considers His Cure by Cluthe Truss Worth a Thousand Dollars+ My rupture has not come down since the day I put on my Cluthe Truss. I followed your instructions, and I must say I have been well rewarded. I would not take $1000 for my truss for I owe my cure to it. You may cheerfully inform the whole world as far as I am concerned, for if I can help others suffering as I did, I certainly will be glad to do so. I am sure it is no disgrace to be ruptured, it is simply a misfortune. I am sure that in most cases of rupture, your truss would soon work a speedy cure as it did for me. EDWARD THEILL, 337 South Main St., Fond du Lac, Wis. October 3, 1911. +Cluthe Truss Cured Him in Less than 3 Months+ I gladly let any one know, and I cannot put it too strongly either, that the Cluthe Truss cured me of my rupture in less than 3 months. J. R. VAN CLEAVE, Strool, South Dakota. October 9, 1911. +Another Rome, N.Y., Man Quickly Cured by Cluthe Truss+ I have only had my Cluthe Truss 7 months, and can now safely go about without any truss, without rupture appearing. I would not be back to where I was before I got my Cluthe Truss for $1000. A. VAN WORMER, Rome, N.Y. September 26, 1911. +Finds a Cure in 3 Months+ The truss I received from you gave me complete satisfaction. I had not worn it 3 months, when I could leave it off as completely cured. I believe it to be the most perfect device for rupture that can be made. I might say a great deal more in its favor, but I am sure that any one who once puts on a Cluthe Truss would never be satisfied with the torturing leg-straps and heavy springs of other trusses. H. O. WEBSTER, Bowell, Ont., Can. October 14, 1911. +Well-Known South Carolinan Cured+ You are at liberty to use this as you please, if it will help any poor sufferer, suffering from rupture as I did before I purchased my Cluthe Truss. I am still using the truss, but my rupture is cured from its use. I have been the means of your selling several of your trusses around here, and I am still doing all I can for you. Your appliance is all and even more than you claim for it. Previously I tried all kinds of trusses that I saw or heard of, but none of them did me any good. W. W. WOOTEN, Bishopville, S.C. September 30, 1911. +Cured Him and His Child+ I don't need to wear any truss at all now, as the truss I purchased from you cured me. It also cured my child of his rupture. J. R. TURNER, 342 Brook Ave., Harrisburg, Pa. October 12, 1911. +Read What This Prominent Bostonian Says+ I am glad to say that the Cluthe Truss I purchased of you a week or so ago, works to perfection. It does the business and completely holds the rupture under all conditions. During the past 60 years, I have tried various trusses and treatments, and all were failures or near-failures. I am more than pleased to be relieved of the annoyances and suffering I have had nearly all my life. I shall take great pleasure in recommending the Cluthe Truss to all I meet, for I am now up for reference. I wish you all success in relieving suffering humanity. HENRY WARREN, 70 Essex St., Boston Mass. September 13, 1911. +His Pleasure to Inform of the Complete Cure by Cluthe Truss+ It is a pleasure for me to inform you of the complete cure in my case by the Cluthe Truss. I wish to say that I have not worn my truss nor any support whatever for 4 months, and I am sound and well, thanks to your treatment. Command me at any time that I may be of service to you or the afflicted, for it is indeed a great pleasure to me to speak a good word for the Cluthe Truss. W. W. WILLIS, Clarksburg, W. Va. September 1, 1911. +Delights in Permanency of His Cure+ The strongest argument I can make, based on my own experience with the Cluthe Truss, is that I have been permanently cured by using it. ALFRED WANDRES, Cornwall Landing, N.Y. October 13, 1911. +A Blessed Day When He Received His Cluthe Truss+ I got a Cluthe Truss from you about 5 months ago, and it has completely cured me. I went without it for 3 weeks, and there is no sign of the rupture coming back. When I received it and put it on, for the first time, I felt instant relief, and knew then that it was going to do me good. It was a blessed day for me when I received my Cluthe Truss. PETER M. STEWART, Boulter, Ont., Can. November 23, 1911. +Now Only Wears It as a Precaution+ I never wear my Cluthe Truss now only when I have some extra heavy lifting to do. I am perfectly cured of my rupture, however, thanks to the Cluthe Truss. GEORGE E. BEALE, Ponca, Ark. November 28, 1911. +Wants Every One to Know that Cluthe Truss is a Necessity for All Ruptured Who Want Relief+ I want every one to know my opinion, which is that the Cluthe Truss is the one that everybody ruptured should get, if they want relief. I have tried many, and have found yours the best and easiest to wear. If I had enough money I would gladly pay the price of a truss to anyone who would not be cured after giving it a trial. That is how I feel about the Cluthe Truss. W. C. WOODS, Gause, Texas. November 23, 1911. +79 Years Old Cured by Cluthe Truss+ It is a pleasure to me to let you and all others know what I think of the Cluthe Truss. My case was a double one, and the rupture on the right side was very bad, but I can truthfully say that I am now cured. I am now living on borrowed time, being in my seventy-ninth year. C. T. REDFIELD, 48 Grape St., New Bedford, Mass. November 28, 1911. +Hard Work Every Day Did Not Prevent This Cure by Cluthe Truss+ I really don't know how to express my gratitude to you for my rupture is cured at last. I feel as strong as I ever did before I was ruptured. I work hard every day and have never had any bad effects. ANDREW E. PETERS, Escuminac River, Que., Can. November 28, 1911. +Cured by Cluthe Truss While Lifting Rails and Ties in the Course of Work+ I have often been without my Cluthe Truss, and rupture has never come down even without the truss. Before getting the Cluthe Truss I had tried many others, but none of them held my rupture continuously, to say nothing of the discomfort caused and chafing by those leg-straps and springs. By reason of my work as section foreman I am frequently required to do heavy lifting, such as railroad rails and ties. This is what I think of the Cluthe Truss. FRANK CHAPMAN, Hollis Depot, N.H. November 27, 1911. * * * * * * * * * * * * * * Errata: The muscles at some point have simply _text reads "simlpy"_ there is no expense beyond the price _text reads "beyonp"_ no springs, no legstraps _no hyphen in original_ and, gradually overcomes the weakness _comma in original_ you who now scarcely _text reads "nows carcely"_ dare do a thing-- scarcely even cough or laugh _dash supplied by transcriber: no punctuation in original_ that is why, when a man _text reads "whan"_ bands or springs around the waist _text reads "wait"_ "Don't-Wear-a-Truss" Arguments _text reads "Dont"_ But it is easy enough _text reads "But it easy"_ The Cluthe Truss costs so little _text reads "cost"_ worthless makeshift _text reads "makeshirt"_ "This truss fully guaranteed." _text reads "guaranted"_ a legitimate profit _text reads "ligitimate"_ Both are perspiration-proof and both water-proof. The Cluthe Truss _text reads "The Cluthe. Truss"_ 60 days' trial.) _close parenthesis missing in original_ agree with the corresponding question.) _close parenthesis missing in original_ do any kind of work _text reads "king"_ 747 E. Main St., Ravenna, Ohio. _comma after "Ravenna" missing_ CHAS. W. SHIVELL period after "CHAS" missing_ To be honest with you, I don't believe I would be here to write this if it had not been for the Cluthe Truss. Can truthfully say I have been wonderfully benefited, and feel as though my rupture is cured _text reads "don?t believe ... if it has not been ... feel aa though"_ My ruptures are so now _text unchanged: missing word after "so"?_ wear it for six months longer _text reads "sic"_ to wear any truss since. From the first day _text has comma for period_ in that time _text reads "yhat"_ Western Bank Note Co., 20th street and Indiana avenue, Chicago, Ill. _capitalization unchanged_ 2844 38th Place, Chicago, Ill. _comma after "Chicago" missing_ I have been permanently cured by using it _text reads "permenantly"_ I can truthfully say that I am now cured _text reads "thaat"_ 
34157	----	Transcriber's note: A few typographical errors have been corrected; they are listed at the end of the text. Page numbers enclosed by curly braces (e.g., {125}) are included in the text to enable the reader to use the "Table of the Chapters" [Table of Contents] which is located at the end of the book. THE _Compleat Surgeon_: OR, The whole Art of _Surgery_ explain'd in a most familiar Method. Containing An exact Account of its Principles and several Parts, _viz._ Of the _Bones_, _Muscles_, _Tumours_, _Ulcers_, and _Wounds_ simple and complicated, or those by _Gun-shot_; as also of _Venereal Diseases_, the _Scurvy_, _Fractures_, _Luxations_, and all sorts of Chirurgical Operations; together with their proper Bandages and Dressings. To which is added, A _Chirurgical Dispensatory_; shewing the manner how to prepare all such Medicines as are most necessary for a Surgeon, and particularly the _Mercurial Panacæa_. * * * * * Written in _French_ by _M. le Clerc_, Physician in Ordinary, and Privy-Counsellor to the _French_ King; and faithfully translated into _English_. * * * * * LONDON, Printed for _M. Gillyflower_, in _Westminster-Hall_; _T. Goodwin_, and _M. Wotton_, in _Fleet-street_; _J. Walthoe_, in the _Middle-Temple_ Cloysters; and _R. Parker_, under the _Royal-Exchange_, in _Cornhill_, 1696. * * * * * THE PREFACE. _So great a number of Treatises of Surgery, as well Ancient as Modern, have been already publish'd, that a plenary Satisfaction seems to have been long since given on this Subject, even to the Judgment of the most curious Inquirers: But if it be consider'd that a young Surgeon ought always to have in view the first Principles of this Noble Art explain'd after a familiar and intelligible manner, it will be soon acknowledg'd that there is good reason to set about_ _the Work anew: For besides that the Writings of the Ancients being so voluminous, are not portable, they are also very intricate and confus'd; nay the whole Art has been so far improv'd and brought to perfection by able Masters in the present Age, that they are now almost become unprofitable._ _Some Modern authors have set forth certain small Tracts, which only explain a few Chirurgical Operations, and on that account deserve only the Name of Fragments. Indeed the Works of some others seem to be sufficiently compleat, but are printed in so large Volumes, and contain so many Discourses altogether foreign from the principal Subject, that they have almost the same Inconveniences with those of the Ancients. Therefore the Reader is here presented with a small Treatise of Surgery, yet very plain and perspicuous, in a portable Volume; being free from a Multiplicity of impertinent Words, and containing every thing of moment that has been producd by the most approv'd Authors both Ancient and Modern._ _An Introduction is made into the Matter by small Colloquies or Dialogues, to the end that the young Student may be at first lead as it were by the Hand; but as soon as he has attain'd to a considerable Progress in these Studies, this innocent and puerile manner of speaking is abandon'd, to conduct him in good earnest to the most sublime Heights of so admirable an Art; to which purpose, after having penetrated into its first Rudiments and Grounds, he is well instructed in Anatomy, and furnish'd with a general _Idea_ of Wounds and Tumours, which are afterward treated of in particular: He is also taught a good Method of curing Wounds made by Gun-shot, the Scurvy, and all sorts of Venereal Diseases: From thence he is introduced into the Practice of all manner of Chirurgical Operations in Fractures and Luxations; together with the use of their respective Dressings and Bandages._ _At the end of the Work is added a _compleat Chirurgical Dispensatory_, shewing the Method of preparing such Medicinal Compositions as are chiefly us'd in the Art of Surgery; so that upon the whole Matter, it may be justly affirm'd, that this little Manual has all the Advantages of the Ancient and Modern Writings on the same Subject, and is altogether free from their Superfluities and Defects._ * * * * * {1} THE _Compleat Surgeon:_ OR, THE Whole ART OF SURGERY Explain'd, _&c._ * * * * * CHAP. I. _Of the Qualifications of a Surgeon, and of the Art of Surgery._ _Who is a Surgeon?_ A Person skill'd in curing Diseases incident to Humane Bodies by a methodical Application of the Hand. _What are the Qualifications of a good Surgeon in general?_ {2} They are three in Number: _viz._ Skill in the Theory, Experience in the Practical part, and a gentle Application of the Hand. _Why ought a Surgeon to be skilful?_ Because without a discerning Faculty he can have no certainty in what he doth. _Why must he be experienc'd?_ Because Knowledge alone doth not endue him with a dexterity of Hand requisite in such a Person, which cannot be acquir'd but by Experience, and repeated Manual Operations. _Why must he be tender-handed?_ To the End that by fit Applications he may asswage those Pains which he is oblig'd to cause his Patients to endure. _What is Chirurgery or Surgery?_ It is an Art which shews how to cure the Diseases of Humane Bodies by a methodical Manual Application. The Term being derived from the _Greek_ Word [Greek: Cheir], signifying a Hand and [Greek: Ergon], a _Work_ or _Operation_. _After how many manners are Chirurgical Operations usually perform'd?_ Four several ways. _Which be they?_ I. _Synthesis_, whereby the divided Parts are re-united; as in Wounds. II. _Diæresis_, that divides and separates those Parts, which, by their Union, hinder the Cure of Diseases, such is the continuity of Abscesses or Impostumes which must be open'd to let out the purulent Matter. III. _Exæresis_, which draws out of the Body whatsoever is noxious or hurtful, as Bullets, Arrows, _&c._ IV. _Prosthesis_ adds some Instrument or Body to supply {3} the defect of those that are wanting; such are Artificial Legs and Arms, when the Natural ones are lost. It also furnishes us with certain Instruments to help and strengthen weak Parts, such as _Pessaries_, which retain the _Matrix_ in its proper place when it is fallen, Crutches to assist feeble Persons in going, _&c._ _What ought to be chiefly observed before the undertaking an Operation?_ Four things; _viz._ 1. What the Operation to be perform'd is? 2. Why it is perform'd? 3. Whether it be necessary or possible? And 4. The manner of performing it. _How may we discern these?_ The Operation to be perform'd may be known by its Definition; that is to say, by explaining what it is in it self: We may discover whether it ought to be done, by examining whether the Distemper cannot be cur'd otherwise: We may also judge whether it be possible or necessary, by a competent Knowledge of the Nature of the Disease, the Strength of the Patient, and the Part affected: Lastly, the manner of performing it may be found out, by being well vers'd in the Practice of Surgery. _What are the Fundamental Principles of Surgery?_ They are Three in number: _viz._ 1. The knowledge of Man's Body. 2. That of the Diseases which require a Manual Operation. 3. That of proper Remedies and Helps upon every Occasion. _How may one attain to the Knowledge of Humane Bodies?_ {4} By the study of Anatomy. _How may one learn to know the Distempers relating to Surgery, and the Remedies appropriated for them?_ Two several ways; _viz._ 1. By the reading of good Books, and Instructions receiv'd from able Masters of that Art. 2. By practice and the Observation of what is perform'd by others upon the Bodies of their Patients. _What are the Diseases in general that belong to Surgery?_ They are Tumours, Impostumes, Wounds, Ulcers, Fractures, Dislocations, and generally all sorts of Distempers whereto Manual Operations may be applyed. _What are the Instruments in general which are commonly used in Surgery for the curing of Diseases?_ They are Five; _viz._ the Hand, Bandages, Medicines, the Incision-Knife, and Fire. _What is the general Practice which ought to be observ'd in the Application of these different helps?_ _Hippocrates_ teacheth us, in saying, that when Medicines are not sufficient, recourse may be had to the Incision-Knife, and afterward to Fire; intimating that we must proceed by degrees. _Are there any Distempers that may be cured by the Surgeon's Hand alone?_ Yes, as when a simple and small Dislocation is only to be reduced. * * * * * {5} CHAP. II. _Of Chirurgical Instruments, portable and not portable._ _What do you call portable and not portable Instruments?_ Portable Instruments are those which the Surgeon carries in his Lancet-Case with his Plaister-Box; and not portable are those that he doth not carry about him, but is oblig'd to keep at home; the former being appointed for the ready help which he daily administers to his Patients, and the others for greater Operations. _What are the Instruments which a Surgeon ought to have in his Plaister-Box?_ These Instruments are a good pair of _Sizzers_, a _Razor_, an _Incision-Knife_ streight and crooked, a _Spatula_, a greater _Lancet_ to open Impostumes, and lesser for letting Blood. They likewise carry separately in very neat Lancet-Cases, a hollow _Probe_ made of Silver or fine Steel; as also many other Probes, streight, crooked, folding, and of different thickness; a _Pipe_ of Silver or fine Steel, to convey the cauterizing _Button_ to a remote Part, without running the hazard of burning those that are near it; another _Pipe_ or _Tube_ serving instead of a Case for _Needles_, which have Eyes at one end for sowing; a _Carlet_, or thick triangular Needle; a small _File_; a Steel Instrument to cleanse the Teeth; a {6} _Fleam_; a pair of crooked _Forceps_ to draw a Tooth; a _Pelican_; a _Crow's Bill_; several sorts of _Raspatories_; a _Hook_ to hold up the Skin in cutting, _&c._ _What are the Instruments which a Surgeon ought to keep in his Repository to perform the greater Operations?_ Some of them are peculiar to certain Operations, and others are common to all. The Instruments appropriated to particular Operations, are the _Trepan_ for opening the Bones in the Head, or elsewhere: The _Catheters_ or Probes for Men and Women afflicted with the Stone, or difficulty of making Water. _Extractors_, to lay hold on the Stone in _Lithotomy_, and to gather together the Gravel; large crooked _Incision-Knives_, and a _Saw_, to make Amputations of the Arms or Legs; great _Needles_ with three Edges, to be used in making _Setons_; small _Needles_ to couch Cataracts; other _Needles_; thin _Plates_ and _Buckles_ to close a Hair-Lip, _&c._ _May not the Salvatory be reckon'd among the portable Instruments?_ Yes, because the Balsams, Ointments, and Plaisters contain'd therein, are means whereof the Surgeon makes use to restore Health. * * * * * {7} CHAP. III. _Of Anatomy in general; and in particular of all the Parts whereof the Humane Body is compos'd._ _What is Anatomy?_ It is the _Analysis_ or exact Division of all the Parts of a Body, to discover their Nature and Original. _What is requisite to be observ'd by a Surgeon before he goes about to dissect a Body?_ Two things; _viz._ The external Structure of the Body, and the Proportion or Correspondence between the outward Parts, and those that are within. _Why so?_ Because without this exterior and general Knowledge, the Surgeon wou'd be often mistaken in the Judgment he is to pass concerning a Dislocation or Wound, inasmuch as it is by the Deformity which he perceives in the Member, that he knows the Dislocation, as it is also by the means of the Correspondence which the outward Parts have with the inward, that he is enabled to draw any certain Consequences relating to a Wound, which penetrates into the Body. _What is a Part?_ It is that whereof the whole Body is compos'd, and which partakes of a common Life or Sensation with it. {8} _How many sorts of Parts are there in a Humane Body?_ We may well reckon up Fifteen distinct Parts, which are the Bone, the Cartilage, the Ligament, the Tendon, the Membrane, the Fibre, the Nerve, the Vein, the Artery, the Flesh, the Fat, the Skin, the Scarf-Skin, the Hair, and the Nails. _What is a Bone?_ It is the hardest and driest Part of the whole Body, and that which constitutes its principal Support. _What is a Cartilage or Gristle?_ It is a yielding and supple Part, which partakes of the Nature of a Bone, and is always fasten'd to its Extremities, to mollifie and facilitate its Motion. _What is a Ligament?_ It is a Membranous Contexture usually sticking to the Bones to contain them; as also sometimes to other Parts, to suspend, and retain them in their proper place. _What is a Tendon?_ It is the Tail or Extremity of the Muscles, made by the re-union of all the Fibres of their Body, which serves to corroborate it in its Action, and to give Motion to the Part. _What is a Membrane?_ It is a Nervous Part, the use whereof is to adorn and secure the Cavities of the Body on the inside, and to wrap up or cover the Parts. _What is a Fibre?_ They are fleshy Lines of which the Body of a Muscle is compos'd. _What is a Nerve?_ It is a long, white, and thin Body, consisting {9} of many Fibres, enclos'd within a double Tunick, and design'd to carry the Animal Spirits into all the Parts, to give them Sense and Motion. _What is an Artery?_ It is a Canal compos'd of Four Coats, that carreyth with a kind of Beating or Pulse even to the very Extremity of the Parts, the Blood full of Spirits, which proceeds from the Heart, to distribute to them at the same time both Life and Nourishment. _What is a Vein?_ It is a Canal made likewise of Four Tunicles, which receives the Arterial Blood, to carry it back to the Heart. _What is Flesh?_ It is a Part which is form'd of Blood thicken'd by the natural Heat; and that constitutes the Body of a Muscle. _What is Fat?_ It is a soft Body made of the Unctuous and Sulphurous part of the Blood. _What is the _Derma_ or Skin?_ It is a Net compos'd of Fibres, Veins, Arteries, Lymphatick Vessels and Nerves, which covers the whole Body to defend it from the Injuries of the Air, and to serve as a universal Emunctory: It is very thin in the Face, sticking close to the Flesh, and is pierc'd with an infinite number of imperceptible Pores, affording a Passage to insensible Transpiration. _What is the _Epiderma_, or Scarf-Skin?_ It is a small fine Skin, transparent and insensible, having also innumerable Pores for the discharging of Sweat, and other Humours by {10} imperceptible Transpiration: It is extended over the whole inner Skin, to dull its too exquisite Sense, by covering the Extremities of the Nerves which are there terminated. It also renders the same Skin even and smooth, and so contributes very much to Beauty. _What is the Hair?_ The Hairs are certain hollow Filaments planted in the Glandules of the Skin, from whence their Nourishment is deriv'd. They constitute the Ornament of some Parts, cover those which Modesty requires to be conceal'd, and defend others from the injury of the Weather. _What is a Nail?_ The Nails are a Continuity of the Skin harden'd at the end of the Fingers, to strengthen and render them fit for Work. * * * * * CHAP. IV. _Of the general Division of a Humane Body._ _How is the Humane Body divided before it is dissected, in order to Anatomical Demonstration?_ Some Anatomists distinguish it into _Similar_ and _Dissimilar_ Parts, appropriating the former Denomination to all the simple Parts of the Body taken separately, as a Bone, a Vein, a Nerve, _&c._ but they attribute the Name of Dissimilar to all those Members that are compos'd of many Similar or Simple Parts together; such are the Arms, {11} Legs, Eyes, _&c._ wherein are contain'd all at once, Bones, Veins, Nerves, and other parts. Others divide it into _containing_ and _contained_ Parts, the former enclosing the others, as the Skull includes the Brain, and the Breast the Lungs; whereas the contained Parts are shut up within others; as the Entrails within the Belly, the Brain within the Skull, _&c._ Others again divide the whole Body into _Spermatick_ and _Sanguineous_ Parts; the former being those which are made at the time of Formation; and the latter all those that are grown afterward by the Nourishment of the Blood. _Are there not also other Methods of dividing the Humane Body?_ Yes: Many Persons consider it as a Contexture of Bones, Flesh, Vessels and Entrails, which they explain in four several Treatises, whereof the first is call'd _Osteology_, for the Bones; the second _Myology_, for the Muscles; the third _Angiology_, for the Veins, Arteries and Nerves, which are the Vessels; and the fourth _Splanchnology_, for the Entrails. But lastly, the most clear and perspicuous of all the Divisions of the Body of Man, is that which compares it to a Tree, whereof the Trunk is the Body, and the Branches are the Arms and Legs. The Body is divided into three _Venters_, or great Cavities, _viz._ the Upper, the Middle, and the Lower, which are the Head, the Breast, and the lower Belly. The Arms are distributed into the Arms properly so called, the Elbow and Hands; and the Legs in like manner into Thighs, Shanks, {12} and Feet: The Hands being also subdivided into the _Carpus_ or Wrist, _Metacarpium_ or Back of the Hand, and the Fingers; as the Feet into the _Tarsus_, _Metatarsus_, and Toes. This vision is at present follow'd in the Anatomical Schools. * * * * * CHAP. V. _Of the Skeleton._ _Why is Anatomy usually begun with the Demonstration of the Skeleton, or Contexture of Bones?_ Because the Bones serve for the Foundation Connexion, and Support of all other Parts of the Body. _What is the Skeleton?_ It is a gathering together, or Conjunction of all the Bones of the Body almost in their Natural Situation. _From whence are the principal differences of the Bones derived?_ They are taken from their Substance, Figure, Articulation, and Use. _How is all this to be understood?_ First then, with respect to their Substance, there are some Bones harder than others; as those of the Legs compared with those of the Back-Bone. Again, in regard of their Figure, some are long, as those of the Arm; and others short, as those of the _Metacarpium_. Some are also broad, as those of the Skull and {13} _Omoplatæ_ or Shoulder-Blades; and others narrow, as the Ribbs. But with respect to their Articulation, some are joined by thick Heads, which are received into large Cavities, as the Huckle-Bones with those of the Hips; and others are united by the means of a simple Line, as the Chin-Bones. Lastly, with relation to their Use; some serve to support and carry the whole Body, as the Leg-Bones, and others are appointed to grind the Meat, as the Teeth; or else to form some Cavity, as the Skull-Bone, and those of the Ribs. _What are the Parts to be distinguished in the Bones?_ They are the Body, the Ends, the Heads, the Neck, the _Apophyses_, the _Epiphyses_, the _Condyli_ or Productions, the Cavities, the _Supercilia_ or Lips, and the Ridges. The Body is the greatest Part, and the middle of the Bone; the Ends are the two Extremities; the Heads are the great Protuberances at the Extremities; the Neck is that Part which lies immediately under the Head; the _Apophyses_ or Processes are certain Bunches or Knobs at the Ends of the Bones, which constitute a Part of them; the _Epiphyses_ are Bones added to the Extremities of other Bones; the _Condyli_ or Productions are the small Elevations or Extuberances of the Bones; the Cavities are certain Holes or hollow places; the _Supercilia_ or Lips are the Extremities of the Sides of a Cavity, which is at the End of a Bone; the Ridges are the prominent and saliant Parts in the length of the Body of the Bone. {14} _How are the Bones join'd together?_ Two several ways, _viz._ by _Articulation_ and _Symphysis_. _How many sorts of Articulations are there in the Bones?_ There are generally two kinds, _viz._ _Diarthrosis_ and _Synarthrosis_. _What is Diarthrosis?_ _Diarthrosis_ is a kind of Articulation which serves for sensible Motions. _How many kinds of Diarthroses, or great Motions are there?_ There are Three, _viz._ _Enarthrosis_, _Arthrodia_, and _Ginglymus_. _Enarthrosis_ is a kind of Articulation which unites two Bones with a great Head on one side, and a large Cavity on the other; as the Head of the Thigh-Bone in the Cavity of the _Ischion_ or Huckle-Bone. _Arthrodia_ is a sort of Articulation, by the means whereof two Bones are join'd together with a flat Head receiv'd into a Cavity of a small depth. Such is the Head of the Shoulder-Bone with the Cavity of the _Omoplata_ or Shoulder-Blade; and that of the Twelfth _Vertebra_ of the Back with the first of the Loins. _Ginglymus_ is a kind of Articulation which unites two Bones, each whereof hath at their Ends a Head and a Cavity, whereby they both receive and are received at the same time, such is the Articulation in the Bones of the Elbow and the _Vertebræ_. _What is _Synarthrosis_?_ _Synarthrosis_ being opposite to _Diarthrosis_, is a {15} close or compacted Articulation, destitute of any sensible Motion. _How many sorts of _Synarthroses_, or close Articulations are there?_ There are Three. _viz._ _Sutura_, _Harmonia_, and _Gomphosis_. A _Suture_ is that which joins together two Bones by a kind of Seam or Stitch, or by a Connexion of their Extremities dispos'd in form of a Saw, the Teeth whereof are reciprocally let one into another: Such are the Sutures of the Skull-Bones. _Harmonia_ is the uniting of two Bones by a simple Line; as the Bone of the Cheek with that of the Jaw. _Gomphosis_ is a kind of close Articulation, which unites two Bones after the manner of Nails or Wooden Pins fixt in the Holes made to receive them: Such is that of the Teeth in their Sockets. _What is _Symphysis_?_ _Symphysis_ is the uniting of two Bones by the interposition of a _Medium_, which ties them very streight together, being also threefold: Such is the Connexion of the Knee-Pan or Whirl-Bone of the Knee, and the _Omoplata_ or Shoulder-Blade. _Are not these three kinds of Articulations or _Symphyses_ distinguish'd one from another?_ Yes; for tho' they are all made by the means of a third Body intervening, which joins them together; nevertheless every one of these various Bodies gives a different Denomination to its respective Articulation: Thus the Articulation which is caus'd by a Glutinous and {16} Cartilaginous Substance, is properly call'd _Synchondrosis_; as that of the Nose, Chin, _Os Pubis_, _&c._ But an Articulation which is made by a Ligament is termed _Synncurosis_, as that of the Knee-Pan. Lastly, that which is wrought by the means of Flesh, bears the Name of _Syssarcosis_; as the Jaw-Bones, the _Os Hyoides_, and the _Omoplata_ or Shoulder-Blade. _Have the Bones any sense of Feeling or Motion?_ They have neither; for their sense of Pain proceeds from nothing else but their _Periostium_, or the Membrane with which they are cover'd, and their Motion is perform'd only by the Muscles that draw them. _Doth the Marrow afford any Nutriment to the Bones?_ No, all the Bones are nourish'd by the Blood, as the other Parts; but the Marrow is to the Bones what the Fat is to the Flesh; that is to say, it is a kind of Oil or Unctuous Substance, which moistens, and renders them less brittle. _Are all the Bones of the same Colour?_ No, they follow the Temperament and Constitution of the Persons. _How many in number are the Bones of the Humane Skeleton?_ There are two hundred and fifty usually reckon'd, _viz._ 61 in the Head, 67 in the Trunk or Chest, 62 in the Arms and Hands, and 60 in the Legs and Feet; but the true Number cannot be exactly determin'd, by reason that some Persons have more, and others fewer; for some have more _Ossa Sesamoidea_, Teeth and {17} Breast-Bones than others: Again, some have many indentings in the _Lambdoidal_ Suture, and others have none at all. _Can you rehearse the Number of the Bones of the Head?_ There are Fifteen in the Skull, and Forty six in the Face. The Fifteen of the Skull are the _Coronal_ for the fore-part of the Head; the _Occipital_ for the hinder-part; the two _Parietals_ for the upper-part and each side; the two _Temporals_ for the Temples; the _Os Sphenoides_ or _Cuneiforme_, which closeth the _Basis_ or bottom of the Skull; the _Os Ethmoides_, or _Cribriforme_, situated at the Root of the Nose; and the four little Bones of the Ear on each side, _viz._ the _Incus_ or Anvil; the _Stapes_ or Stirrup; the _Malleolus_ or Hammer; and the _Orbiculare_ or Orbicular Bone. Of the Forty six of the Face, Twenty seven are counted in the Upper-Jaw, _viz._ the two _Zygomatick_, or the two Bones of the Cheek-Knots; the two _Lachrymal_ in the great Corners of the Eyes toward the Nose; the two _Maxillar_, that receive the Upper-Teeth, and which form part of the Palate of the Mouth, and the Orbits of the Eyes; the two Bones of the Nose; the two Palate-Bones which are at its end, and behind the Nostrils; the last being single is the _Vomer_, which makes the Division of the lower part of the Nostrils; and there are generally Sixteen Upper-Teeth. The Lower-Jaw contains Nineteen Bones, _viz._ sixteen Teeth; two Bones that receive them; and the _Os Hyoides_, which is single, and fix'd at the Root of the Tongue. {18} _How are the Teeth usually divided with respect to their Qualities?_ Into _Incisive_ or Cutters, _Canine_ or Dog-Teeth, and _Molar_ or Grinders: There are eight Incisive, and four Canine, which have only one single Root; as also twenty Molar, every one whereof hath one, two, or three Roots. _Can you recite the Number of the Bones of the Trunk or Chest?_ There are generally thirty and three in the _Spine_ or Chine-Bone of the Back, _viz._ seven _Vertebra's_ in the Neck, twelve in the Back, five in the Legs, five, six, and sometimes seven in the _Os Sacrum_, three or four in the _Coccyx_, and two Cartilages at its end. There are twenty nine in the Breast, _viz._ twenty four Ribs, two Clavicles or Channel-Bones and commonly three Bones in the _Sternum_. The Hip-Bones are likewise divided into three, _viz._ _Ilion_, _Ischion_ and _Os Pubis_. _Do you know the Number of the Bones of the Arms?_ There are thirty and one Bones in each Arm, that is to say, the _Omoplata_ or Shoulder-Blade; the _Humerus_ or Shoulder-Bone; the two Bones of the Elbow call'd _Ulna_, and _Radius_; eight little Bones in the _Carpus_ or Wrist; five in the _Metacarpium_ or Back of the Hand; and fourteen in the Fingers, three to every one except the Thumb, which hath only two. _Can you give us a List of the Bones of the Leg in their Order?_ There are thirty Bones in each Leg, _viz._ the _Femur_ or great Thigh-Bone, the Knee-Pan or {19} Whirl-Bone on the top of the Knee; the _Tibia_, _greater Focile_, or Shin-Bone; and the _Perone_ or _Fibula_, or _lesser Focile_, which are the two associated Bones of the Leg; seven little Bones in the _Tarsus_; five in the _Metatarsus_; and fourteen in the Toes; that is to say, three to every one, except the great Toe, which hath only two. Thus the Number of Bones of the Humane _Skeleton_ amounts to two hundred and Fifty, without reckoning the _Sesamoides_, the Indentings of the Skull, and some others which are not always to be found. * * * * * CHAP. VI. _Of Myology, or the Anatomy of the Muscles of a Humane Body._ _What is a Muscle?_ It is the principal Organ or Instrument of Motion; or it is a Portion of Flesh, wherein there are Veins, Arteries, Nerves, and Fibres, and which is cover'd with a Membrane. _How many parts are there in a Muscle?_ Three, _viz._ the Head, the Belly, and the Tail: The Head is that part thro' which the Nerve enters; the Belly is the Body or Middle of the Muscle; and the Tail is the Extremity, where all the Fibres of the Muscle are terminated to make the Tendon or String which is fasten'd to the Part whereto it gives Motion. {20} _Have all the Muscles their Fibres streight from the Head to the Tail?_ No, some have them streight, others transverse, and others oblique or circular, according to the several Motions to which they are appropriated. _How many sorts of Muscles are there with respecting to their Action?_ There are two different kinds, _viz._ the _Antagonists_ and the _Congenerate_; the former are those that produce opposite Motions; as a _Flexor_ and an _Extensor_, a _Depressor_ and a _Levator_. The Congenerate are those that contribute to one and the same Action; as when there are two Flexors or two Extensors, and then one supplies the defect of the other; whereas when one of the Antagonist Muscles is cut, the other becomes useless, and void of Action. _How is the Action of a Muscle perform'd?_ It is done by Contraction and Extension; the former causeth the Antagonist to swell, and the other compels it to stretch forth in length. _What is _Aponeurosis_?_ It is the continuity of the Fibres of a Tendon which makes a Connexion that serves to strengthen the Muscle in its Motion. * * * * * {21} CHAP VII. _Of the Myology, or Anatomy of the Muscles of the Head._ _How many Muscles are there appointed to move the Head, and which be they?_ The Head is mov'd by the means of fourteen Muscles, seven on each side; of these, two serve to depress it, eight to lift it up, and four to turn it round about. The two Depressors are call'd _Sternoclinomastoidei_; they take their Rise in the _Sternum_, at the Clavicles, and proceed obliquely to join the _Apophysis Mastoides_. Of the four Elevators on each side the first is the _Splenius_, which begins at the five _Vertebræ_ of the Back and the three lower ones of the Neck, and ascending obliquely, cleaves to the hinder part of the Head. The second, named _Complexus_ or _Trigeminus_, having its beginning as the _Splenius_, sticks in like manner to the hinder part of the Head, and they form together a figure resembling that of S. _Andrew_'s Cross. The third is the _Rectus Major_, which proceeding from the second _Vertebra_ of the Neck, shoots forward to join the hinder part of the Head. The fourth is the _Rectus Minor_, which begins at the first _Vertebra_ of the Neck, and ends likewise in the hinder part of the Head. The two Muscles on each side, which move the Head circularly, are the _Obliquus Major_ and {22} _Minor_; the _greater Oblique_ taking its rise from the second _Vertebra_ of the Neck, goes to meet the first; but the _lesser Oblique_ hath its Origine in the hinder part of the Head, and proceeds to join the other obliquely in the first _Vertebra_. _How many Muscles are there in the Lower-Jaw, and which be they?_ The Lower-Jaw hath twelve Muscles which cause it to move; that is to say, six on each side, whereof four serve to close and two to open it. The first of the Openers is the _Latus_, which beginning at the top of the _Sternum_, Clavicle, and _Acromion_, cleaves on the outside to the bottom of the Lower-Jaw-Bone. The second of the Openers is the _Digastricus_, which takes its rise in a Fissure lying between the Occipital Bone and the _Apophysis Mastoides_, from whence it passeth to the bottom of the Chin on the inside. The first of the Shutters is the _Crotaphites_ or Temporal Muscle, which hath its Origine at the bottom, and on the side of the _Os Coronale_, the _Os Parietale_, and the _Os Petrosum_, from whence it is extended till it cleaves to the _Apophysis Coronoides_ of the Lower-Jaw, after having passed above the _Apophysis_ of the _Zygoma_: Its Fibres are spread from the Circumference to the Center, and it is covered again with the _Pericranium_, which renders its Wounds very dangerous; so that the least Incisions as can be, ought to be made therein. The second is the _Pterygoideus_ or _Aliformis Externus_, whose rise is in the _Apophysis Pterygoides_, from whence it sets forward till it stick between the _Condylus_ and the Coronal of the Lower-Jaw. The third is the _Masseter_, which hath two {23} Sources or Beginnings, and as many Insertions; the first Source thereof is at the Cheek-Knot or Ball of the Cheek, and the second at the lower part of the _Zygoma_. The first Insertion is at the outer Corner of the Jaw, and the second in the middle part, by that means forming the Figure of the Letter X. The fourth is the _Pterygoideus_ or _Aliformis Internus_, which hath its beginning in the _Apophysis Pterygoides_, and is terminated in the inner Corner of the Jaw; so that Mastication or Chewing is perform'd by the means of these four Muscles. _How many Muscles are there in the Face, and which be they?_ There are two for the Forehead, call'd _Frontal_, whose Origine is in the upper part of the Head, from whence they descend by streight Fibres, until they are fasten'd in the Skin of the Forehead near the Eye-Brows, where they are re-united: Their Action or Office is to draw the Skin of the Forehead upward, whereto they stick very close. There are also two others call'd _Occipital_, which have their Beginning in the same place with the preceeding, but they descend backward, and cleave to the Skin of the hinder part of the Head, which they draw upward. There are two Muscles to each Eye-Lid, one whereof is termed the _Attollens_ or _Elevator_ and the other the _Depressor_. The Elevator takes its rise in the bottom of the Orbit of the Eye, and is fastned by a large _Aponeurosis_ to the edge of the upper Eye-Lid. The Shutter or Depressor, call'd also the _Orbicular_, hath its Origine in the great _Canthus_, or Corner of the Eye, passeth over the {24} Eye-Lid upward, and is join'd to the lesser Corner of the same Eye, being extended along its whole Compass. The Eyes have each six Muscles, _viz._ four _Recti_ and two _Obliqui_; the _Recti_ or streight Muscles are the _Elevator_, the _Depressor_, the _Adductor_, and the _Abductor_. The first of these call'd _Elevator_, or _Superbus_, draws the Eye upward, as it is pull'd downward by the _Depressor_ or _Humilis_; the _Adductor_ or _Bibitorius_ draws it toward the Nose, and the _Abductor_ or _Indignarorius_ toward the Shoulder: All these small Muscles have their Originals and Insertions in the bottom of the Orbit through which the Optick Nerve passeth, and are terminated in the Corneous Tunicle, by a very large _Tendon_. The first of the Oblique ones is term'd the _Obliquus Major_, and the other _Obliquus Minor_, because they draw the Eye obliquely. These Muscles cause Children to squint when they do not act together. The _Obliquus Minor_ is fasten'd at the outward part of the Orbit near the great Corner, and draws the Eye obliquely toward the Nose: But the _Obliquus Major_ is fixt in the inner part of the Orbit, and ascends along the Bone to the upper part of the great Corner, where its Tendon passeth thro' a small Cartilage nam'd _Trochlea_, and is inserted in the little Corner with the lesser _Obliquus Minor_, to draw the Eye obliquely toward the lesser Corner. The Ear, altho' not usually endu'd with any sensible Motion, nevertheless hath four Muscles, _viz._ one above, and three behind; the first being situated over the Temporal, and fasten'd to the Ear to draw it upward: The three others have {25} their beginning in the _Mammillary Apophysis_, and are terminated in the Root of the Ear, to draw it backward. There are also three Muscles in the inner part of the Ear, whereof the external belonging to the _Malleus_ or Hammer lies under the exterior part of the Bony Passage which reacheth from the Ear to the Palate of the Mouth, being fixt in a very oblique Sinuosity which is made immediately above the Bone that bears the Furrow, into which is let the Skin of the _Tympanum_ or Drum. The internal Muscle lies hid in a Bony Semi-Canal, in the _Os Petrosum_; one part of which Semi-Canal is without the Drum, and clos'd on the top with a Passage that leads from the Ear into the Palate. But the other part within the Drum advanceth to the _Fenestra Ovalis_, and is inserted in the hinder part of the Handle of the _Malleus_. The Muscle of the _Stapes_ or Stirrup is also hid in a Bony Tube, almost at the bottom of the Drum, and fixt in the Head of the _Stapes_. The Nose hath seven Muscles, that is to say, one common and six proper; the common constitutes part of the orbicular Muscle of the Lips, and draws the Nose downward with the Lip. Of the six proper Muscles of the Nose, four serve to dilate it, being situated on the outside, and two to contract it, which are placed in the inside. The two first Dilatators of a Pyramidal Figure, take their rise in the Suture of the Forehead, and are fasten'd by a large Filament to the _Alæ_ of the Nose. The two other Dilatators resembling a Myrtle-Leaf have their Source in {26} the Bone of the Nose, and are inserted in the middle of the _Ala_. The two Restrictors are Membranous, beginning in the internal part of the Bone of the Nose and adhering to the inner _Ala_ of the Nostril. The Lips have thirteen Muscles, _viz._ eight proper, and five common: Of the proper there are four for the Upper-Lip, and as many for the Lower: with two common for each, and the odd one. The first of the proper of the Upper-Lip bears the Name of the _Incisivus_, its Origine being in the Jaw, in the place of the Incisive Teeth and its Insertion is in the Upper-Lip. The second is the _Triangulis_, Antagonist to the former; its Rise is on the outside, at the bottom of the Lower-Jaw; and it is implanted in the Upper-Lip, near the Corner of the Mouth. The third being the _Quadratus_, springs from the bottom of the Chin before, and cleaves to the edge of the Lower-Lip. The fourth is the _Caninus_, Antagonist to the _Quadratus_, beginning in the Upper-Jaw-Bone and being terminated in the Lower-Lip near the Corner of the Mouth. The first of the common is the _Zygomaticus_, the Origine whereof is in the _Zygoma_ and its Insertion in the Corner of the Mouth, to draw it toward the Ears; so that it is the Muscle which acts when we laugh. The second of the common is the _Buccinator_ or Trumpeter, which is swell'd when one sounds a Trumpet. It hath its rise at the Root of the Molar Teeth of both the Jaws, and is extended quite round about the Lips. {27} The odd Muscle, or the thirteenth in number, is the _Orbicular_, which makes a _Sphincter_ round about the Lips to close or shut them up. The _Uvula_ or Palate of the Mouth hath four Muscles, whereof the two first are the _Peristaphylini Externi_, taking their rise from the Upper-Jaw, above the Left Molar Tooth, and being ty'd to the Palate by a thin _Tendon_. The two others are the _Peristaphylini Interni_, which have their beginning in the _Apophysis Pterygoides_ on the inside, and likewise stick to the Palate. The Tongue, altho' all over Musculous and Fibrous, yet doth not cease to have its peculiar Muscles, which are eight in Number. The first of these is call'd _Genioglossus_, taking its rise in the lower part of the Chin, from whence it is extended till it cleave to the Root of the Tongue before, to cause it to go out of the Mouth. The second is term'd _Styloglossus_, its Rise being in the _Apophysis Styloides_, from whence it passeth to the side above the Tongue, to lift it up. The third bearing the Name of _Basiglossus_, commenceth in the _Basis_ or Root of the _Os Hyoides_, and thence insinuates it self into the Root of the Tongue, to draw it back to the bottom of the Mouth. The fourth is the _Ceratoglossus_, deriving its Original from the Horn of the _Os Hyoides_, and cleaving to the side of the Tongue to draw it on one side: The Action of these Muscles of both sides together, causeth an Orbicular Motion in the Tongue. To these some add a fifth {28} Pair of Muscles, call'd _Myloglossus_, which serves to draw it obliquely upward. _What is the Action of the _Os Hyoides_ in the Throat, and how many Muscles hath it?_ The use of the _Os Hyoides_ is to consolidate the Root of the Tongue; and it hath five Muscles on each side, which keep it as it were hung up. The first of these, call'd the _Geniohyoideus_ hath its beginning in the Chin on the inside, and adheres to the top of the _Os Hyoides_, which it draws upward. The second is the _Mylohyoideus_, whose Origine is in the inner side of the Jaw, from whence it cleaves side-ways to the Root of the _Os Hyoides_, which it draws upward, and to one side. The third is the _Stylohyoideus_, which after it hath taken its rise in the _Apophysis Styloides_, is fasten'd to the Horn of the _Os Hyoides_, to draw it toward the side. The fourth is the _Coracohyoideus_, which springing up from the _Apophysis Coracoides_ of the _Omoplata_, cleaves to the Root and side of the _Os Hyoides_, to draw it downward and to the side. The fifth is the _Sternomohyoideus_, that hath its beginning in the Bone of the _Sternum_ on the inside and is inserted in the Root of the _Os Hyoides_, which it draws downward. _How many Muscles hath the _Larynx_?_ There are fourteen, _viz._ four Common, and ten Proper. The first Pair of the Common is the _Sternothyroideus_ or _Bronchycus_, which proceeding from the inside, and the top of the _Sternum_, ascends along the Cartilages of the Wind-Pipe, and is terminated in the bottom of the {29} _Scutiformis_ or Buckler-like Cartilage, which it draws downward. The second is the _Hyothyroideus_, which ariseth from the Root of the _Os Hyoides_, and is inserted in that of the _Scutiforme_. This Muscle serves to lift up the _Larynx_, as also to dilate the bottom of the _Scutiformis_, and to close its top. The first Pair of the Proper is the _Cricothyroideus Anticus_, which deriving its Original from the hinder and upper part of the _Cricoides_, or Ring-like Cartilage, is fixt in the upper and lateral part of the _Scutiformis_, to close or shut it up. The second is the _Thyroides_. The third is the _Cricoarytenoideus Lateralis_, which proceeds from the side of the _Cricoides_ within, and is fasten'd to the bottom and side of the _Arytenoides_, which it removes to dilate the Mouth of the _Larynx_. The fourth is the _Thyroarytenoideus_, which arising from the fore-part on the inside of the _Scutiformis_, is terminated on the side of the _Arytenoides_, to close the Orifice of the _Larynx_. The fifth is the _Arytenoideus_, which having its Source in that place where the _Cricoides_ is united to the _Arytenoides_ is inserted in its upper and lateral part, to close the _Larynx_. _How many Muscles hath the _Pharynx_?_ It hath seven, the first whereof is the _Oesophagieus_, which takes its rise from the side of the _Scutiformis_ or Buckler-like Cartilage, and passing behind the _Oesophagus_ or Gullet, is fasten'd to the other side of the Cartilage. It thrusts the Meat down by locking up the _Pharynx_ as a _Sphincter_. The second named _Stylopharingæus_, springs from within the Acute _Apophysis_ of the _Os Sphenoides_, or _Cuneiforme_, and is inserted obliquely {30} in the side of the _Pharynx_, which it dilates by drawing it upward. The third, call'd _Sphenopharyngæus_, proceeds from the _Apophysis Styliformis_, and is terminated in the side of the _Pharynx_, which it dilates by drawing its sides. The fourth Pair is the _Cephalopharyngæus_ which ariseth from the articulation of the Head with the first _Vertebra_, and closeth the _Larynx_. _How many Muscles are there in the Neck, and which be they?_ There are four Muscles in the Neck on each side, _viz._ two Flexors, and two Extensors. The _Flexors_ are the _Scalenus_ and the _Rectus_ or _Longus_; and the Extenders are the _Spinatus_ and the _Transversalis_. The _Scalenus_ or _Triangularis_ hath two remote Sources, _viz._ one in the first Rib, and the other in the Clavicle, and is fasten'd to the third and fourth _Vertebra_ of the Neck. The _Rectus_ or _Longus_ begins in the side of the four upper _Vertebra's_ of the Back, and is join'd to the upper _Vertebra's_ of the Neck, and the hinder part of the Head. The _Spinatus_ hath its Origine in the fourth and fifth upper _Vertebra's_ of the Back, and is fasten'd to all the six lower _Vertebra's_ of the Neck. The _Transversalis_ springs forth out of the upper _Vertebra's_ of the Back, and cleaves to the Extremity of the four _Vertebra's_ of the Neck. * * * * * {31} CHAP. VIII. _Of the Myology or Anatomy of the Muscles of the Chest; or of the Breast Belly, and Back._ _How many Muscles are there in the Breast, and which be they?_ The Breast hath fifty seven Muscles, that is to say, thirty that serve to dilate it, twenty six whose Office is to contract it, and the _Diaphragm_ or Midriff, which partakes of both Actions. The thirty which dilate the Breast are equally plac'd to the number of Fifteen, _viz._ the _Subclavius_, the _Serratus Major Anticus_, the two _Serrati Postici_, and the eleven external _Intercostals_. The twenty six which contract the Breast are likewise equally rank'd to the Number of thirteen on each side, _viz._ the _Triangularis_, the _Sacrolumbus_, and eleven internal _Intercostals_. The _Subclavian_ takes up the whole space between the Clavicle and the first Rib: Its Original being in the internal and lower part of the _Clavicula_, and its insertion in the upper part of the first Rib. The _Serratus Major_ is a large Muscle having seven or eight Indentings or Jaggs. It takes its rise in the interior Basis of the _Omoplata_ or Shoulder-Blade, and its Jaggings are inserted in {32} the five lower true Ribs, as also in the two upper spurious Ribs. The _Serratus Posticus Superior_, begins with a large _Aponeurosis_ in the _Apophyses_ of the three lower _Vertebræ_ of the Neck, and of the first of those of the Back; then passing under the _Rhomboid_, it is join'd obliquely by four Indentings to the four upper Ribs. The _Serratus Posticus Inferior_, commences in like manner with a large _Aponeurosis_ in the _Apophyses_ of the three lower _Vertebra's_ of the Back, and of the first of those of the Loins, and is afterwards fasten'd by four Digitations to the four lower Ribs. The eleven _External Intercostal_ Muscles are situated in the spaces between the twelve Ribs passing obliquely and on the outside from the back part to the fore part. They take their rise below the Upper Rib, and have their Insertion above the lower Rib. The _Triangularis_ is the first of those that contract the Breast, and possesseth the inward part of the _Sternum_: Its Original is in its lower part, and its Insertion in the top of the Cartilages of the two upper Ribs. The _Sacrolumbus_ hath its Source in the hinder part of the _Os Sacrum_, as also in the _Vertebra's_ of the Loins, and ascending from thence, insinuates it self into the hinder part of the Ribs, to every one of which it imparts two _Tendons_, one whereof sticks on the outside, and the other on the inside. This Muscle is fleshy within, and fibrous without. The Eleven _Internal Intercostals_, contrary to the External, derive their Original from the {33} top of every lower Rib, and ascend obliquely from the back-part to the fore-part, till they are join'd to the lower Lip of every upper Rib: Thus these Internal Muscles, with the External, form, by the opposition of their Fibres, a Figure resembling a _Burgundian_ Cross. The Diaphragm or Midriff is esteem'd as the fifty seventh Muscle of the Breast, and serves as well for its dilatation as contraction. It separates the _Thorax_ or Chest from the lower Belly, and is tied circularly to all the Extremities of the Bastard Ribs, immediately under the _Xiphoides_, or Sword-like Cartilage. Modern Anatomists have discover'd that the Diaphragm is compos'd of two Muscles, _viz._ one Upper, and the other Lower; so that the Upper cleaves to the Extremities of the Spurious Ribs, and is terminated in a flat _Tendon_ in the middle, which hath been always taken for its Nervous part. The Lower begins with two Productions, the longest whereof being on the right side, ariseth from the three upper _Vertebra's_ of the Loins, and the other on the Left from the two _Vertebra's_ of the Back, till it is lost in the _Aponeurosis_ of the Upper Muscle. _How many Muscles are there in the Back and the Loins, and which be they?_ There are three in each side, _viz._ one for Flection, and the other for Extension. The _Triangularis_ is the _Flexor_, taking its rise in the hinder part of the Rib of the _Os Ilion_, and the inner part of the _Os Sacrum_, in passing from whence it is joined to the last of the {34} Bastard Ribs, and to the transverse Productions of the _Vertebra's_ of the Loins. The _Extensors_ are the _Sacer_, and the _Semi-spinatus_, which make the Waste streight, and are so interwoven along the Back-Bone, that one would imagine that there were as many Pairs of Muscles as _Vertebra's_, affording _Tendons_ to all. The _Sacer_ springs from behind the _Os Sacrum_, as also from the hinder and upper Extremity of the _Os Ilium_, and is inserted in the Spines of the _Vertebra's_ of the Loins and Back. The _Semi-spinatus_ hath its Source in the Spines of the _Os Sacrum_, and is join'd to all the transverse Productions of the _Vertebra's_ from the Back to the Neck, being exactly situated between the _Sacer_ and the _Sacrolumbus_. * * * * * CHAP. IX. _Of the Myology, or Anatomy of the Muscles of the lower Belly._ _How many Muscles are there in the lower Belly, and which be they?_ There are generally ten, five on each side, that is to say, two _Obliqui_, one ascending, and the other descending; one _Transversus_, one _Rectus_, and two Pyramidal, of which last, nevertheless, there is sometimes only one, and sometimes none at all. {35} The _Obliquus Descendens_, which is the first, hath its Original by digitation in the sixth and seventh of the true Ribs, in all the spurious Ribs, and in the transverse _Apophyses_ of the _Vertebra's_ of the Loins, and comes near to the _Serratus Major Anticus_ of the Breast; from whence it proceeds to the external Rib of the _Os Ilion_, and is terminated by a large _Aponeurosis_ in the _Linea Alba_ or _White Line_, which separates the Muscles that are on each side of the _Abdomen_ or lower Belly. The _Obliquus Ascendens_ ariseth from its Source in the upper part of the _Os Pubis_, and in the Ridge of the Hip-Bone, till it cleaves to the _Apophyses_ of the _Vertebra's_ of the Loins in the Extremities of all the Ribs, and in the _Xiphoides_ or Sword-like Cartilage, and is terminated in the White Line by a large _Aponeurosis_. The _Rectus_ being situated between the _Aponeuroses_ of the _Obliquus_, takes its rise in the Cartilages of the Ribs, in the _Xiphoides_ and the _Sternum_, and enters into the _Os Pubis_, having many nervous parts to corroborate it in its length. The _Transversus_ having its beginning in the transverse _Apophyses_ of the _Vertebra's_ of the Loins, is fasten'd to the internal Rib of the _Os Ilium_, and within the Cartilages of the lower Ribs, and is terminated by a large _Aponeurosis_ in the _Linea Alba_, passing over the _Rectus_, and sticking to the _Peritonæum_. The Oblique Muscles, and the Transverse, have Holes toward the Groin, to give Passage to the Spermatick Vessels of Men, and to a round {36} ligament of the _Matrix_ in Women; so that Ruptures or Burstenness happen through these parts in both Sexes, although the Holes of these three Muscles are not situated one over-against another. The Pyramidal, so named by reason of its Figure, is situated in the lower _Tendon_ of the _Rectus_, its Origine being in the upper and external part of the _Os Pubis_; but it is terminated in the White Line, three Fingers breadth above the _Pubes_, and sometimes even in the Navel itself. These Muscles are not found in all Bodies for there are sometimes two, sometimes only one, and sometimes none. The use of the Muscles of the lower Belly is to compress all the contain'd parts, in order to assist them in expelling the Excrements. _How many Muscles are there in the Testicles?_ They have each of them one, call'd _Cremaster_; this Muscle takes its rise from the Ligaments of the _Os Pubis_, and by the dilatation of its Tendon covers the Testicle, which it draws upward. _How many Muscles hath the _Penis_?_ It hath two Pair, _viz._ the _Erectores_ or _Directores_, and the _Dilatantes_: The _Erectores_ arise from the internal part of the _Os Ischion_, under the beginning of the _Corpora Cavernosa_, where they are inserted, and retake their Fibres in their Membranes. The _Dilatantes_ or _Acceleratores_ have their Source in the _Sphincter_ of the _Anus_ and slipping from thence obliquely under the _Ureter_, are join'd to the Membrane of the Nervous Bodies. _How many Muscles are there in the _Clitoris_?_ {37} It hath two Erectors which spring forth from the Protuberance of the _Os Ischion_, and are inserted in the Nervous Bodies of the _Clitoris_. There are also two others suppos'd to be its Elevators, which proceed from the _Sphincter_ of the _Anus_, and are terminated in the _Clitoris_. _How many Muscles are there in the _Anus_?_ There are three, _viz._ the _Sphincter_, and two _Levatores_. The _Sphincter_ is two Fingers broad, to open and close the _Rectum_. This Muscle being double, is fasten'd in the fore-part to the _Penis_ in Men, and to the Neck of the _Matrix_ in Women, as also behind to the _Coccyx_, and laterally to the Ligaments of the _Os Sacrum_, and the Hips. The two _Levatores_ arise from the inner and lateral part of the _Os Ischion_, and are fasten'd to the _Sphincter_ of the _Anus_, to lift it up after the expulsion of the Excrements. The _Bladder_ hath also a _Sphincter_ Muscle to open and shut its Orifice. * * * * * CHAP. X. _Of the Muscles of the _Omoplatæ_, or Shoulder-Blades, Arms, and Hands._ _How many ways doth the _Omoplata_ or Shoulder-Blade move, and what are its Muscles?_ The _Omoplata_ moves upward, downward, forward, and backward, by the means of four proper Muscles, which are the _Trapezius_, the {38} _Rhomboides_, the proper _Levator_, and the lesser _Pectoral_, or _Serratus Minor Anticus_. The _Trapezius_ or _Cucullaris_ hath its beginning in the back part of the _Occiput_, or hinder part of the Head, in the Spines of the six lower _Vertebra's_ of the Neck, and of the nine upper of the Back, in passing from whence it is implanted in the Spine of the _Omoplata_ or Shoulder-Blade, and the external part of the _Clavicula_, as far as the _Acromion_. This Muscle produceth many Motions by reason of its different Fibres, drawing the Shoulder-Blade obliquely upward, downward, and forward. The _Rhomboides_ is situated over the _Trapezius_, its rise being in the _Apophyses_ of the three lower _Vertebra's_ of the Neck, and of the three upper of the Back, but it is afterward join'd to the whole _Basis_ or Root of the _Omoplata_, which it draws backward. The proper _Levator_ commenceth in the _Transverse Apophyses_ of the four first _Vertebra's_ of the Neck, by different Progressions, but is afterward re-united, and inserted in the upper Corner of the _Omoplata_, which it draws upward. The _lesser Pectoral_, or _Serratus Minor Anticus_, is situated under the great _Pectoral_, its rise being by Digitation or Indenting in the second, third, and fourth of the upper Ribs, and its Insertion in the _Apophysis Coracoides_ of the Shoulder-Blade, which it draws forward. _How many Motions are there in the _Humerus_, or Arm; which be they, and what are its Muscles?_ {39} The Arm performs all sorts of Motions by the help of nine Muscles: For it is lifted up by the _Deltoides_ and the _Infra-Spinatus_; it is depress'd by the _Largissimus_, and the _Rotundus Major_; it is drawn forward by the _Pectoralis Major_, and the _Coracoideus_; it is drawn backward by the _Infra-Spinatus_, and the _Rotundus Minor_. It is drawn near the Ribs by the _Subscapularis_, and its circular Motion is performed when all these Muscles act together successively. The _Deltoides_ or _Triangular_ hath its beginning in the whole Spine of the _Omoplata_, the _Acromion_, and half the _Clavicula_, and by its point cleaves with a strong _Tendon_ to the middle of the Arm. The _Infra-Spinatus_ takes its rise in the Cavity that lies above the Spine of the _Omoplata_, which it fills, passing over the _Acromion_, until it is join'd to the Neck of the Shoulder-Bone, which it surrounds with a large _Tendon_. The _Largissimus_, otherwise call'd _Ani-scalptor_, covers almost the whole Back, proceeding from a large and Nervous Stock, in the third and fourth lower _Vertebra_ of the Back, the five _Vertebra's_ of the Loins, the Spine of the _Os Sacrum_, the hinder part of the Lip of the Hip-Bone, and the external part of the lower Bastard-Ribs, in passing from whence it insinuates it self into the lower Corner of the _Omoplata_, as also into the upper and inner part of the _Humerus_. The _Rotundus Major_, or _Teres Major_, having its Origin in the external Cavity of the lower Corner of the _Omoplata_, is confounded with the _Largissimus_, and adheres with it by the same {40} _Tendon_ to the upper and inner part of the _Humerus_, a little below the Head. The greater _Pectoral_ hath its Source in half the _Clavicula_, on the side of the _Sternum_; covers the fore-part of the Breast, and is fasten'd by a short, broad, and nervous _Tendon_, to the top of the Shoulder-Bone, on the inside, between the _Biceps_ and the _Deltoides_. The _Coracoideus_ or _Coracobrachyæus_, beginning in the _Apophysis Coracoides_ of the _Omoplata_ or Shoulder-Blade, adheres to the middle of the Arm on the inside, which with the _Pectoral_ it draws forward. The _Infra-Spinatus_ fills the Cavity which lies below the Spine of the _Omoplata_, its Origine being in the lower Rib of the _Omoplata_, from whence it passeth between the Spine and the _Rotundus Minor_, to cleave to the Neck of the Shoulder-Bone, which it embraceth, and draws backward. The _Rotundus Minor_, or _Teres Minor_, proceeds from the lower Rib of the _Omoplata_, and adheres to the Neck of the Shoulder-Bone with the _Infra-Spinatus_ to draw it in like manner backward. The _Sub-scapularis_ or _Immersus_ is situated entirely under the _Omaplata_, proceeding from the internal Lip of the _Basis_ or Root of the same _Omoplata_, and being terminated in the Neck of the Arm-Bone, which it causeth to lie close to the Ribs. _How many Motions are there in the_ Cubitus _or Elbow, and what are its Muscles?_ The _Cubitus_ or _Ulna_ is endu'd with two sorts of Motions, _viz._ that of Flection and that of {41} Extension, the former being perform'd by the help of two Muscles, that is to say, the _Biceps_, and the _Brachiæus Internus_; and the later by eight others, which are the _Longus_, the _Brevis_, the _Brachiæus Externus_, and the _Anconeus_. The _Biceps_ is a Muscle with two Heads, one whereof proceeds from the _Apophysis Coracoides_, and the other from the Cartilaginous edge of the _Glenoid_ Cavity of the _Omoplata_ or Shoulder-Blade: These two Heads descend along the fore-part of the Arm, and are united in one and the same Body, from whence springs forth a Ligament, which is inserted in a tuberosity situated in the upper and fore-part of the _Radius_. The _Brachiæus Internus_ is a small fleshy Muscle, lying hid under the _Biceps_, which takes its rise in the upper and fore-part of the _Humerus_, and is implanted in the upper and inner-part of the _Radius_, to bend the Elbow with the _Biceps_. The first of the four Extenders is the _Longus_ having two Sources, _viz._ one situated in the lower Rib of the _Omoplata_, near its Neck, and the other descending to the hinder-part of the Arm, till it is tyed to the _Olecranum_ or _Ancon_, by a strong _Aponeurosis_, which is common thereto, with the _Brevis_, and the _Brachiæus Externus_. The _Brevis_ or short Muscle of the Elbow arising from the hinder and upper-part of the _Humerus_, is fasten'd to the _Olecranum_ with the _Longus_. The _Brachiæus Externus_ is a fleshy Muscle which proceeds from the hinder part of the {42} _Humerus_, and adheres to the _Olecranum_ with the _Brevis_ and the _Longus_. The _Anconeus_ or _Cubitalis_ being situated behind the Fold of the _Cubitus_, is the least Muscle of all; it springs from the Extremity of the Arm-Bone, at the end of the _Brevis_ and the _Longus_, and in descending is inserted between the _Radius_ and the _Cubitus_ or _Ulna_, three or four Fingers breadth below the _Olecranum_. _How many Muscles hath the _Radius_, and which are its Motions?_ The _Radius_ is endu'd with a twofold Motion by the means of four Muscles: Of these the _Rotundus_ and _Quadratus_ cause that of _Pronation_, as the _Longus_ and the _Brevis_ that of _Supination_. The _Pronator Superior Rotundus_, or round Muscle of the _Radius_, commenceth from the inner _Apophysis_ of the Shoulder-Bone, in a very fleshy Stock, and is terminated obliquely by a Membranous _Tendon_ in the middle and exterior part of the _Radius_. The _Pronator Inferior Quadratus_, springing forth from the bottom and inside of the _Cubitus_, is fixt in the lower and outward part of the _Radius_ by a Tail as large as its Head. This Muscle lying hid under the others near the Wrist, is that which jointly with the _Rotundus_, turns the Arm with the Palm of the Hand downward, which is the Motion of _Pronation_. The _Longus_ is the first of the _Supinators_, whose Origine is three or four Fingers breadth above the external _Apophysis_ of the Arm-Bone; from whence it passeth along the _Radius_, and cleaves to the inner-part of its lower _Apophysis_. {43} The _Brevis_, or the second of the _Spinators_ arising from the lower part of the _Inferior Condylus_, and the external of the _Humerus_, is twisted round about the _Radius_, going forward from the hinder-part till it is united to its upper and forepart. This Muscle, with the _Longus_, serves to turn the Arm and the Palm of the Hand upward, and produceth the Motion of _Supination_. _How many sorts of Motions belong to the Wrist, and what are its Muscles_? Two several Motions are perform'd by the Wrist, _viz._ one of Flection, and the other of Extension, three Muscles being appropriated to the former, and as many to the later: But it ought to be observed, that a strong Ligament, call'd the _Annular_, appears here, which, surrounding all the _Tendons_ of the Muscles as it were a Bracelet, holds them together, and elsewhere serves to unite the two Bones of the Elbow. The three Flexors or Bending Muscles of the Wrist are the _Cubitæus Internus_, the _Radiæus Internus_, and the _Palmaris_. The _Cubitæus Internus_ derives its Original from the part of the Arm-Bone, passeth under the Annular Ligament, and is ty'd by a thick _Tendon_ to the small Bone of the Wrist, which is plac'd above the others. The _Radiæus Internus_ proceeds from the same place with the _Cubitæus_, and is fasten'd to the first Wrist-Bone which supports the Thumb. It lies along the _Radius_, and passeth under the _Annular_ Ligament. The _Palmaris_ is reckon'd among the Flexors of the Wrist, although situated in the Palm of the Hand. It ariseth from the inner Process or Knob {44} of the Arm-Bone, and is united by a large _Tendon_ to the first _Phalanges_ of the Fingers, slipping under the Transverse or _Annular_ Ligament and sticking under the Skin of the Palm of the Hand. The three extending Muscles of the Wrist are the _Cubitæus Externus_, and the _Radiæus Externus_ or the _Longus_, and the _Brevis_. The _Cubitæus Externus_ taking its rise from the hinder-part of the Elbow, passeth under the _Annular_ Ligament, and adheres to the upper and outward-part of the Bone of the _Metacarpus_ that stayeth the little Finger. The _Radiæus Externus_, or the _Longus_, having its Origine in the edge of the lower part of the Arm-Bone, slides from thence along the _Radius_ on the outside, extends it self under the _Annular_ Ligament, and cleaves to the Wrist-Bone, which stayeth the Fore-Finger. The _Brevis_ or _short_ Muscle of the Wrist springs from the lower part of the same Edge; afterwards it runs along the _Radius_, passeth under the _Annular_ Ligament, and is terminated in the Bone of the _Carpus_ or Wrist, which stayeth the Middle Finger. But we must take notice, that besides these six Muscles, there is also _Caro quædam quadrata_, or a square piece of Flesh under the _Palmaris_, which seems to arise from the _Thenar_, and sticks to the eighth Wrist-Bone. It is supposed that this Musculous piece of Flesh serves with the _Hypothenar_ of the little Finger, to make that which is call'd _Diogenes's Cup_. _How many Motions are there in the Fingers, and what are their Muscles_? {45} The Fingers are bent, extended, and turn'd from one side to the other by the means of twenty-three Muscles, whereof ten are proper, and thirteen common: The former are those that serve all the Fingers in general, and the other those that are particularly serviceable to some of them: The Common are the _Sublimis_, the _Profundus_, the common _Extensor_, the four _Lumbricales_, and the six _Interossei_. The _Sublimis_ or _Perforatus_, arising from the internal part of the lower Process of the _Humerus_ or Shoulder-Bone is divided into four _Tendons_, which run below the _Annular_ Ligament of the Wrist, and are inserted in the second _Phalanx_ of the Bones of the four Fingers, after having stuck in passing to those of the first _Phalanx_, to help to bend it. It is also observed that every one of these _Tendons_ hath a small cleft in its length, to let in the _Tendons_ of the _Profundus_. The _Profundus_ or _Perforans_ lies under the _Sublimis_, deriving its Original from the top of the _Cubitus_ and _Radius_. It creeps along these two Bones, and is divided into four _Tendons_, which pass under the _Annular_ Ligament, and slip into the Fissures of the _Tendons_ of the _Sublimis_, to adhere to the third _Phalanx_ of the Fingers, which they bend with the _Sublimis_: So that these two Muscles make together the bending of the Fingers. The _Extensor Magnus_ is that which extends the four Fingers. It springs from the external and lower Process of the Arm-Bone, and is divided into four flat _Tendons_, which pass under the _Annular_ Ligament, and cleave {46} to the second and third _Phalanx_ of the Fingers. The four _Lumbricales_ or _Vermiculares_ are in the Palm of the Hand, to draw the Fingers to the Thumb: They proceed from the _Tendons_ of the _Profundus_, and the _Annular_ Ligament, extend themselves along the sides of the Fingers and are inserted in their second Articulation, to cause the drawing toward the Thumb. The three _Interossei Interni_, and the three _Externi_, are situated between the four Bones of the _Metacarpium_, as well on the inside of the Hand as without: They have their beginning in the Intervals or Spaces between the Bones of the _Metacarpium_, are united with the _Lumbrical_, and fixt in the last Articulation of the Bones of the Fingers, to produce the Motion of drawing back or removing from the Thumb. The Thumb is mov'd by five particular Muscles; one whereof serves to bend it, two to extend it, one to remove it from the Fingers, and another to draw it to them. The _Flexor_ of the Thumb takes its rise from the upper and inner part of the _Radius_, passes under the _Annular_ Ligament, as also under the _Thenar_, and adheres to the first and second Bones of the same Thumb to bend it. The two _Extensors_ of the Thumb are the _Longior_ and the _Brevior_: The former proceeding from the upper and outward part of the _Cubitus_, ascends above the _Radius_, and is ty'd with a forked _Tendon_ to the second Bone of the Thumb. The _Brevior_ hath the same Origin with the _Longior_, keeps the same Track, passes under the _Annular_ Ligament, and is terminated in the third Thumb-Bone. {47} The _Thenar_ removes the Thumb from the Fingers, and forms that part which is call'd the _Mount of Venus_: It hath its Source in the first Bone of the _Carpus_ or Wrist, and the _Annular_ Ligament, and is inserted in its second Bone. The _Antithenar_ draws the Thumb to the other Fingers, having its Origine in the Bone of the _Metacarpus_, that stayeth the middle Finger, and its Insertion is in the first Bone of the Thumb. The Muscle which serves to extend the Fore-Finger, is call'd _Indicator_: It proceeds from the middle and outer part of the _Cubitus_, and is fixt by a double _Tendon_ in the second Articulation of the Fore-Finger, as also in the _Tendon_ of the great _Extensor_ of the Fingers. That which draws the Fore-Finger to the Thumb is term'd _Adductor_: It commenceth in the fore-part of the first Thumb-Bone, and is terminated in the Bones of the Fore-Finger. That which removes the Fore-Finger from the Thumb is known by the Name of _Abductor_, which arising out of the external and middle part of the Bone of the Elbow, and passing under the _Annular_ Ligament, cleaves to the Lateral and outward part of the Bones of the Fore-Finger. The Little-Finger hath two proper Muscles, _viz._ an _Extensor_ and an _Abductor_. The _Extensor_ springs from the lower part of the _Condylus_ of the Arm-Bone, and is fasten'd by a double _Tendon_ in the second Articulation of the Little-Finger, and in the _Tendon_ of the _Extensor_ of all the others. {48} The _Abductor_, call'd also _Hypothenar_, hath its beginning in the small Bone of the Wrist, which is situated over the others, and is terminated in the first Bone of the Little-Finger on the outside. * * * * * CHAP. XI. _Of the Muscles of the Thighs, Legs, and Feet._ _What are the Motions of the Thighs?_ The Thigh performs five kinds of Motions; for it is bent, extended, drawn within side and without, and turn'd round: All these Motions are produc'd by the means of fourteen Muscles, _viz._ three _Flexors_, three _Extensors_, three _Adductors_, three _Abductors_, and two _Obturators_ for the Circular Motion. The _Flexors_ of the Thigh are the _Psoas_, _Iliacus_, and _Pectineus_. The _Psoas_ or _Lumbaris_ is situated inwardly in the _Abdomen_, on the side of the _Vertebra's_. It proceeds from the transverse _Apophyses_ of the two lower _Vertebra's_ of the Back, and of the upper of the Loins, and lying on the inner Face of the _Os Ilion_, sticks to the lesser _Trochanter_ or _Rotator_. The _Iliacus Internus_ hath its Origine in all the Lips of the inner Cavity of the _Os Ilion_, and being joyn'd by a _Tendon_ to the _Lumbaris_, is inserted with it in the lesser _Trochanter_. {49} The _Pectineus_ takes its rise from the fore-part of the _Os Pubis_, and is united before to the Thigh-Bone a little below the lesser _Trochanter_. The _Extensors_ of the Thigh are the _Glutæus Major_, _Medius_, and _Minimus_. The _Glutæus Major_ springs forth out of the lateral part of the _Os Sacrum_, as also the hinder and outer part of the _Os Ilion_ and _Coccyx_, and enters into the Thigh-Bone, four Fingers breadth below the great _Trochanter_ or _Rotator_, being the thickest of all the Muscles of the Body. The _Glutæus Medius_, deducing its Original from the hinder and outward part of the _Os Ilion_, is inserted three Fingers breadth below the great _Trochanter_. The _Glutæus Minimus_ ariseth from the bottom of the Cavity of the _Os Ilion_, and is fasten'd to a small Hole near the great _Trochanter_. The _Adductors_ of the Thigh are the _Triceps Superior, Medius_, and _Inferior_. The _Triceps Superior_ hath its beginning in the top of the _Os Pubis_, and is terminated in the top of a Line, which is on the inside of the Thigh. The _Triceps Medius_ proceeding from the middle of the _Os Pubis_, is inserted in the Thigh-Bone a little lower than the _Triceps Superior_. The _Triceps Inferior_ hath its Source in the bottom of the _Os Pubis_, and is implanted in the Thigh-Bone, a little lower than the _Triceps Medius_. Some Anatomists make only one Muscle of these three, attributing thereto three Originals and three Insertions. These Muscles serve to draw the Thighs one against another. The _Abductors_ of the Thigh are the _Iliacus Externus_, or _Pyriformis_, the _Quadratus_, and the _Gemelli_. {50} The _Pyriformis_ arising from the upper and lateral part of the _Os Sacrum_, and the the _Os Ilion_ cleaves to the Neck of the great _Trochanter_. The _Quadratus_ or square Muscle of the Thigh takes its Origine from the external Prominence of the _Os Ischion_, and adheres to the outward part of the great _Trochanter_. The _Gemelli_ or Twin Muscles arise from two small Knobs in the hinder-part of the _Ischion_ and insinuate themselves into a small Cavity in the Neck of the great _Trochanter_. The Circular Motion of the Thigh is performed by the means of two Muscles, named the _Obturatores Externi_ and _Interni_. The _Obturator Internus_ springs from the inner Circumference of the Oval Hole of the _Ischion_ and its _Tendons_ passing between the two _Gemelli_ are inserted in a small Cavity at the Root of the great _Trochanter_ or _Rotator_. The _Obturator Externus_ ariseth from the outward Circumference of the same Hole of one _Ischion_, and is terminated in the side of the other near the great _Trochanter_. _What are the Motions of the Leg, and what are its Muscles?_ The Leg is mov'd four several ways, that is to say, it is bent, extended, and drawn inward and outward, by the means of eleven Muscles _viz._ three _Flexors_, four _Extensors_, two _Adductors_ and two _Abductors_. The three _Flexors_ of the Leg are the _Biceps_, the _Semi-nervosus_, and the _Semi-membranosus_. The _Biceps_ hath two Heads, the longer whereof cometh out of the bottom of the Prominence {51} of the _Ischion_, and the other from the middle and exterior part of the _Femur_, and is terminated in the outward and upper part of the _Epiphysis_ of the _Perone_ or _Fibula_. The _Semi-nervosus_ hath its Origine in the Knob of the _Ischion_, and is join'd backward to the top of the _Epiphysis_ of the _Tibia_. These three Muscles are plac'd in the back-part of the Thigh below the Buttocks. The four _Extensors_ of the Leg are the _Rectus_, the _Vastus Internus_, the _Vastus Externus_, and the _Crureus_. The _Rectus_ or streight Muscle of the Leg takes its rise from the fore-part and the bottom of the _Ilion_, and descends in a right Line: It covers with its _Tendon_, which is common to the three following, the whole Knee-Pan, and adheres to the top of the _Tibia_, on the fore-part. The _Vastus Internus_, being situated on the inside of the Thigh, hath its beginning in the top of the Thigh inwardly, and a little below the lesser _Trochanter_ or _Rotator_: Afterward it is ty'd to the _Tibia_ by a large _Tendon_, common thereto with the preceeding. The _Vastus Externus_ is plac'd on the outside of the Thigh, springing from the top and the fore-part of the _Femur_, being united by the same _Tendon_ with the two preceeding. The _Crureus_ proceeds from the top, and the fore-part of the Thigh-Bone, between the two _Trochanters_; then covering the whole Bone, it is also fasten'd to the Leg-Bone with the three preceeding Muscles, after having cover'd the Knee-Pan with their common {52} _Tendon_, which serves likewise as a Ligament to the Knee. The two _Adductors_ of the Leg are the _Sartorius_ and the _Gracilis_. The _Sartorius_ or the _Longissimus_ draws the leg inward, deriving its Original from the upper _Spine_ of the _Ischion_; from whence it descends obliquely thro' the inside of the Thigh, and cleaves to the top on the inside of the _Tibia_. The _Gracilis_ hath its Origine in the fore-part at the bottom of the _Os Pubis_, and its Insertion in the top of the _Tibia_ on the inside. The two _Abductors_ of the Leg are the _Fascia lata_, and the _Poplitæus_. The _Fascia lata_, or the _Membranosus_, is as it were a kind of large Band, which covers all the Muscles of the Thigh. It proceeds from the outward Lip of the _Os Ilion_, is ty'd by a large Membrane to the top of the _Perone_ or _Fibula_ and sometimes descends to the end of the Foot. The _Poplitæus_, or _Sub-poplitæus_, arises from the lower and external _Condylus_ of the Thigh-Bone, passeth obliquely from the outside to the inside, till it is lost in the upper and inner part of the Leg-Bone under the Ham. _What are the Motions of the Foot, and what are its Muscles?_ The Foot performs two Motions by the help of nine Muscles, as being bent by two, and extended by seven. The two _Flexors_ are the _Crureus Anticus_, and the _Peronæus Anticus_. The _Crureus_ or _Tibiæus Anticus_, is plac'd along the _Tibia_, and takes its rise from its upper and fore-part: Afterward it is bound by two {53} _Tendons_ to the first _Os Cuneiforme_, or Wedge-like Bone, and to that of the _Metatarsus_ or Instep, which stayeth the great Toe, after having pass'd under the annular Ligament. The _Peronæus Anticus_ springs from the middle and outward-part of the _Perone_ or _Fibula_, and insinuating it self thro' the Cleft which is under the external _Malleolus_ before, sticks to the Bone of the _Metatarsus_ that supports the little Toe. The seven _Extensors_ of the Foot are the two _Gemelli_, or the _Soleus_, the _Plantaris_, the _Crureus Posticus_, and the two _Peronæi Postici_. The _Gemelli_ are the _Interior_ and the _Exterior_; the former having its Source in the inner _Condylus_, and the other in the outward and lower of the Thigh-Bone; from whence they extend themselves till they are fasten'd to the _Talus_ or Ankle-Bone by a _Tendon_ common to them, with the two following. The _Soleus_ ariseth from the top on the back-part of the Leg-Bone and _Perone_, and confounding its _Tendon_ with that of the _Gemelli_, sticks close to the _Talus_. The _Plantaris_, which lies hid between the _Gemelli_ and the _Soleus_, hath its Origine from the _Exterior Condylus_ of the Thigh-Bone; then uniting its _Tendon_ with the preceeding, it adheres to them; and this common _Tendon_ is call'd _Chorda Achillis_. The _Crureus_ or _Tibiæus Posticus_, springs from the back-part of the Leg-Bone, from whence extending it self downward, it passeth thro' the Fissure in the _Internal Malleolus_, and cleaves to the inner-part of the _Os Scaphoides_. {54} The _Peronæi_, or _Fibulæi Postici_, are otherwise call'd the _Longus_ and the _Brevis_, whereof one proceeds from the upper and almost fore-part of the _Perone_, terminating in the upper-part of the Bone, that supports the great Toe in the _Metatarsus_, and the other from the lower part of the _Perone_, adhering in like manner to the Bone with which the little Toe is sustain'd. _With what Motions are the Toes endu'd, how many Muscles have they, and which be they?_ The Toes are bent and extended, as also drawn inward and outward, by the means of twenty two Muscles, of which sixteen are Common, and six Proper. The former are two _Flexors_, two _Extensors_, four _Lumbricales_, and eight _Interossei_. The first _Flexor_ is nam'd _Sublimis_, and the other _Profundus_. The _Sublimis_ or _Perforatus_ derives its Original from the lower and inner-part of the _Talus_ and is fixt in its proper place by four cleft _Tendons_, which are inserted in the upper-part of the Bones of the first _Phalanx_ of the four Toes. It is situated under the Sole of the Feet. The _Profundus_ or _Perforans_ hath its beginning in the top and back-part of the Leg-Bone and _Perone_, slips under the _Malleolus Internus_ thro' the _Sinus Calcaris_, and makes four _Tendons_ which pass thro' the Fissures of the _Tendon_ of the _Sublimis_, and cleaves to the Bones of the last _Phalanx_ of the Toes, to bow them. The first _Extensor_ is call'd the _Common_, and the other the _Pediæus._ The _Common Extensor_, or the _Longus_, takes its rise from the top and fore-part of the _Tibia_ in the place of its joyning with the _Perone_ or {55} _Fibula_, and divides it self into four _Tendons_, which after having pass'd under the Annular Ligament, are inserted in the Articulations of every Toe. The _Pediæus_ or the _Brevis_, being plac'd over the Foot, proceeds from the Annular Ligament, and the lower-part of the _Perone_, and sends forth four _Tendons_, which are fixt to the first Articulation of the four Toes on the outside, Thus this Muscle, together with the _Longus_, causeth their Extension. The four _Lumbrical_ Muscles of the Toes arise from the _Tendons_ of the _Profundus_, and a Mass of Flesh at the Sole of the Feet. They are joyn'd by their _Tendons_ with those of the _Interossei Interni_, and adhere inwardly to the side of the first Bones of the four Toes, to incline them toward the great Toe. The _Abductors_, or those Muscles that remove the Toes from the great Toe, are the eight _Interossei_, whereof four are call'd _Externi_, and as many _Interni_. The former take their rise in the Spaces between the Bones of the _Metatarsus_, and are terminated outwardly in the side of the first Bones of the Toes. The Internal lie in the bottom of the Foot, and take up the Spaces between the five Bones of the _Metatarsus_. They arise from the Bones of the _Tarsus_, and the Intervals between those of the _Metatarsus_, and are implanted with the four _Lumbricales_ inwardly, in the upper-part of the Bones of the first _Phalanx_ of the four Toes. Of the six Proper Muscles of the Toes, there are four appointed for the great Toe, which cause it to perform the Motions of Flexion, {56} Extension, and drawing forward or backward. The two others are the _Adductor_ of the second Toe to the great Toe, and the _Abductor_ of the little Toe, call'd _Hypothenar_. The Proper _Flexor_ of the great Toe, arises from the top of the _Perone_ or _Fibula_, on the back part, passeth thro' the Ancle-Bone on the inside to the sole of the Foot, and is fasten'd to the Bone of the last _Phalanx_. The Proper _Extensor_ of the great Toe springs from the middle of the fore-part of the _Perone_, passeth over the Foot, and hath its Insertion in the upper-part of the Bone of the great Toe. The Proper _Adductor_ of the great Toe, or the _Thenar_, taking its rise inwardly on the side of the _Talus_, the _Ossa Schaphoidea_ and _Innominata_, extends it self over the outward-part of the Bone of the _Metatarsus_, which stayeth the great Toe, and adheres to the top of the second Bone of the great Toe, which it draws inward. The proper _Abductor_ of the great Toe, or the _Antithenar_, draws it toward the other Toes. It derives its Origine from the Bone of the _Metatarsus_, which supports the little Toe, slides obliquely over the other Bones, and cleaves to the first Bone of the great Toe on the inside. The _Adductor_ appropriated to the second Toe hath its Source in the first Bone of the great Toe, on the inside, and sticks close to the Bones of the second Toe, which it draws to the great Toe. {57} The _Abductor_ of the little Toe, or the _Hypothenar_, proceeds from the outward part of the Bone of the _Metatarsus_, that stayeth the little Toe, and is inserted in the top of the little Toe, on the outside, to remove it from the others. _A List of all the Muscles in the Humane Body._ The Fore-head hath two Muscles 2 The hinder-part of the Head 2 The Eye-Lids 4 The Eyes 12 The Nose 7 The Ears on the outside 8 The Ears on the inside 6 The Lips 13 The Tongue 8 The _Uvula_, or Palate of the Mouth 4 The _Larynx_ 13 The _Pharynx_ 7 The _Os Hyoides_ 10 The Lower Jaw 12 The Head 14 The Neck 8 The _Omoplatæ_ or Shoulder-Blades 8 The Arms 18 The Elbows 12 The _Radii_ 8 The Wrists 12 The Fingers 48 The Breast, or the Parts of Respiration 57 The Loins 6 The _Abdomen_ or lower Belly 10 The Testicles 2 The Bladder 1 {58} The _Penis_ 4 The _Clitoris_ 4 The _Anus_ 3 The Thighs 30 The Legs 22 The Feet 18 The Toes 44 Total 425 * * * * * CHAP. XII. _Of the Anatomy of the Nerves, Arteries, and Veins in general._ _What is the Structure of the Nerves?_ The Nerves are round white Bodies enclos'd in a double Membrane, communicated to them from the two _Meninges_ of the Brain: Their Office is to convey the Animal Spirits into all the Parts. _Where is the Root and first beginning of all the Nerves?_ All the Nerves take their Original from the _Medulla Oblongata_, and that of the Spine. _How is the distribution of them made thro' the whole Body?_ It is directly perform'd by Conjugations or Pairs, whereof one goes to the Right-hand, and the other to the Left: There are nine Pairs of them that proceed from the _Medulla Oblongata_ and enter into the Skull; and a Tenth that comes from the Marrow which lies between the Occipital and the first _Vertebra_ of the Neck. It {59} passeth thro' the Hole of the _Dura Mater_, thro' which the Vertebral Artery enters, to distribute its Branches into several Parts. _To what Use are the nine Pairs of Nerves appropriated, which proceed from the Root of the Brain?_ They are chiefly design'd for the Senses, and also for the Motion of their Organs, of which the Ancients discover'd only seven. The first Pair of Nerves is call'd the _Olfactory_, and serves for the Smelling. The second Pair is the _Optici_ or _Visorii Nervi_, and bestows upon the Eyes the Faculty of seeing. The third is term'd _Motorii Oculorum_, being serviceable for the Motion of the Eyes. The fourth Pair is nam'd _Oculorum Pathetici_, which shews the Passion of the Mind in the Eyes, whereto it imparts a String as well as to the Lips. The fifth is call'd the _Gustative_, and appropriated to the Taste, because it sends Twigs more especially to the Tongue, as also to the Fore-head, Temples, Face, Nostrils, Teeth, and Privy-Parts. The Sixth is likewise for the Taste, and goes to the Palate. The seventh is the _Auditive_ Nerve, that enters into the _Os Petrosum_, where it divides it self into many Branches, which when gone forth, are distributed to the Muscles of the Tongue, Lips, Mouth, Face, Fore-head, Eye-Lids, &c. The eighth is the _Os Vagum_, or wandering Pair, which is united to the Intercostal Nerve, as also to the Recurrent, Diaphragmatick, Mesenterick, &c. {60} The ninth Pair, after having form'd a Trunk with the eighth, disperseth its Twigs several ways, whereof one is join'd with the Twig to the tenth, to be distributed together into the Muscle _Sternohyoideus_, and into the Tongue. The _Intercostal_ and _Spinal_ are not Pairs of Nerves, but only Branches or Twigs of other Pairs. _What is the Distribution and Use of the thirty Pairs of Nerves that proceed from the Spinal Marrow?_ There are seven that go forth from the several _Vertebra's_ of the Neck, twelve from those of the Back, five from the Loins, and six from the _Os Sacrum_, according to the following Progression. The first of the seven Pairs of Nerves of the Neck proceeds from between the Occipital Bone and the first _Vertebra_, nam'd _Atlas_, its Fibres being lost in the Muscles of the hinder-part of the Head and Neck. The second Pair springs from between the first and second _Vertebra_ of the Neck; the Fibres whereof are lost in the Muscles of the Head, and in the Skin of the Face. The third Pair issueth from between the second and third _Vertebra_ of the Neck; and its Fibres are lost in the Flexor Muscles and Extensors of the Neck. The fourth, fifth, sixth, and seventh Pairs proceed from between the _Vertebra's_, as before, but their Fibres are lost in the Neck of the _Omoplata_, in the Arm, and in the _Diaphragme_ or Midriff. Here it ought to be observ'd by the way that the Arms receive Branches not only from the {61} four last Pairs of the Nerves of the Neck, but also from the two first Pairs of the Back, which are extended even to the end of the Fingers: Whence it happens that in the Palsie of the Arms, Remedies are usually apply'd to the _Vertebra's_ of the Neck; and that in Phlebotomy or letting Blood, care must be taken to avoid pricking the Nerve, which accompanies the Basilick Vein in the Elbow. The twelve Pairs of Nerves that have their Beginning from between the _Vertebra's_ of the Back, are each of them divided into two Branches, as the others; and their Branches are distributed in like manner to the Muscles of the Breast, and to those of the Back and _Abdomen_. The five Pairs which take their Rise from between the _Vertebra's_ of the Loins, have thicker Branches than the others, and the distribution of them is made to the Muscles of the Loins, _Hypogastrium_, and Thighs. Of the six Pairs of Nerves that proceed from the _Os Sacrum_, the four Upper with the three Lower of the Loins, send forth Fibres of Nerves to the Thigh, Leg, and Foot; and the two last Pairs impart Nerves to the _Anus_, Bladder, and privy Parts. _What is the Structure of the Arteries?_ The Arteries are long and round Canals, consisting of four sorts of Tunicks or Membranes, which have their Rise from the left Ventricle of the Heart, from whence they receive the Blood, and convey it to all the Parts of the Body for their Nourishment. _What is the Construction of these four Tunicks or Membranes of the Arteries?_ {62} The first being thin and Nervous in its outward Superficies, is in the Inside a _Plexus_ or Interlacement of small Veins and Arteries, and Fibres of Nerves, which enter into the other following Tunicks, to nourish them. The second sticking close to the former, is altogether full of whitish Glandules, that serve to separate the serous Particles of the Blood. The third is intirely Musculous, and interwoven with Annular Fibres. The fourth is very thin, and hath its Fibres all streight. _Whence proceeds the Pulse or beating of the Arteries?_ It is deriv'd from the Heart, and exactly answers to its Motion of _Diastole_ and _Systole_. _By what Name is the first Trunk of the Arteries call'd, and what is the Effect of the Distribution made thence to the whole Body?_ The first Trunk of the Arteries is nam'd _Aorta_, or the _thick Artery_, which proceeds immediately from the left Ventricle of the Heart, whereto it communicates before its departure from the _Pericardium_, one or two small Branches call'd the _Coronary_: Afterward it is divided into two Branches, whereof one goes upward, and is term'd the _Ascending Artery_; and the other downward, under the Denomination of the _Descending Artery_. The _Ascending Artery_ ariseth upward along the _Aspera Arteria_ or Wind-Pipe, to the Clavicles, and is there divided into two Branches, call'd the _Subclavian Arteries_, one whereof goes forward to the Right side, and the other to the Left; and they both send forth on each side {63} divers Branches, which take their Names from the several Parts, whereto they are distributed; such are the _Carotides_ or _Soporales Interni & Externi_, which pass to the Head; the _Mediastina_; the _Intercostal_; the _Axillar_, and others. The _Descending Artery_, before its departure from the Breast, affords certain Branches to the _Pericardium_, Diaphragm, and lower Ribs; afterward it penetrates the Diaphragm, and constitutes seven double Branches. The first is of those that are call'd _Coeliack_, and which go to the Liver and Spleen. The second Branch contains the _Upper Mesenterick_. The third the _Emulgent_, which pass to the Reins. The fourth the _Spermatick_, which are extended to the Genitals. The fifth the _Lower Mesenterick_. The sixth the _Lumbar_. And the seventh the _Muscular_. But assoon as the great Trunk is come downward to the _Os Sacrum_, it divides it self into two thick Arteries nam'd the _Iliack_, which are distributed on both sides, each of them making two Internal and External Branches, which likewise impart Sprigs or lesser Arteries, to the Bladder, _Anus_, _Matrix_, and other adjacent Parts: Then the Master-Branch forms the _Crural_ Arteries on the inside of the Thighs, which are communicated by multiplying their Number even to the ends of the Toes, in passing over the External Ancle-Bones of the Feet. _What is the Structure of the Veins?_ The Veins are long and round Canals made of four kinds of Tunicks or Membranes, whose Office it is to receive the Blood that remains after the Nourishment is taken, and to carry it back to the Heart to be reviv'd. {64} _What is the Form of the four Tunicks that make the Canals of the Veins?_ The first is a Contexture of Nervous and streight Fibres. The second is a _Plexus_ of small Vessels that carry the Nourishment. The third is all over beset with Glandules thro' which are filtrated the serous Particles of the Blood contain'd in the Vessels of the second Tunicle. The fourth is a Series of Annular and Musculous or Fleshy Fibres. _Which are the most numerous, the Arteries or the Veins?_ The Number of the Veins exceeds that of the Arteries; and there are scarce any Arteries without Veins accompanying them. _Where is the Beginning and Original of all the Veins?_ All the Veins have their Root in the Liver, and two of the three great Trunks that proceed from thence, are call'd _Vena Portæ_, and _Vena Cava_; and the third is twofold, _viz._ the _ascending_ and the _descending_. The _Vena Portæ_ is distributed to all the Parts contain'd in the lower Belly, and terminated in the Fundament; where it makes the Internal Hæmorrhoidal Veins. The _Vena Cava_ is immediately divided into two thick Branches, one whereof ariseth upward to the Right Ventricle of the Heart, and forms the _ascending Vena Cava_; as the other goes downward to the Feet, and constitutes the _descending_. _What is the Distribution of the ascending _Vena Cava_?_ It perforates the Diaphragm, goes to the Heart, and ascends from thence to the Clavicles, {65} after having communicated to the Midriff in passing, a small Branch call'd the _Phrenicus_; as also one or two to the Heart, nam'd the _Coronary_; and some others to the upper Ribs, besides the single Branch, term'd _Azygos_, only on the right side. But the Trunk of the _ascending Vena Cava_, being once come up to the Clavicles, is divided into two Branches, well known by the Name of the _Subclavian_, one whereof Shoots forth toward the Right side, and the other toward the Left; and they both make various Ramifications like to those of the thick ascending Artery, by producing the _Cervicalis_ or _Soporalis_, and the Internal and External _Jugulars_ that go to the Head; as also the _Axillars_, which pass to the Arms and Shoulders, forming the _Cephalick_, the _Median_, and the _Basilick_ on the inside of the Elbow. The _descending Vena Cava_ in like manner accompanieth the Ramifications of the _Aorta_, or thick descending Artery, to the fourth _Vertebra_ of the Loins, where it sends forth two Branches, nam'd the _Iliack_, one whereof goes to the Right side, and the other to the Left, both inwardly and outwardly; imparting divers Twigs or lesser Branches to all the Parts contain'd in the _Abdomen_ or lower Belly, even as far as the Fundament, where it makes the External _Hæmorrhoidal_ Veins. Afterward the outward Branch of the _Iliack_ descends in the Thigh, to form the _Crural_, and others, as far as the _Saphæna_, together with those that are situated at the end of the Feet. * * * * * {66} CHAP XII. _Of the Anatomy of the _Abdomen_, or lower Belly_. _What is the clearest Division of the Human Body into various Parts, and that which is most followed in the Anatomical Schools?_ It is that which constitutes three _Venters_, that is to say, the Upper, the Middle, and the Lower, which are the Head, the _Thorax_ or Breast and the _Abdomen_ or lower Belly, together with the Extremities, which are the Arms and Legs. _What is the lower Belly?_ It is a Cavity of the Body that contains the nourishing parts, as the Reins, the Bladder, and all those that are appropriated to Generation in both Sexes. _What is to be consider'd outwardly in the lower Belly?_ Its different Regions, and the several parts therein contain'd. _What are these Regions?_ They are the _Epigastrick_, the _Umbilical_, and the _Hypogastrick_. _What is their Extent?_ It is from the _Xyphoides_ or Sword-like Cartilage to the _Os Pubis_, the division whereof into three equal Parts, constitutes the three different Regions; the _Epigastrium_ being the first upward, the _Umbilicus_ the second, and the _Hypogastrium_ the third. {67} _What Are the Parts contain'd in the _Epigastrium_, and what Place do they possess therein?_ The Parts contain'd in the _Epigastrium_ are the Liver, the Spleen, the Stomach, and the _Pancreas_ or Sweet-bread, which lies underneath: The Stomach takes up the middle before, the Liver being plac'd on the Right side, and the Spleen on the Left; so that these two sides of the Epigastrick Region, are call'd the Right and Left _Hypochondria_. _What Parts are there contain'd in the Umbilical Region, and what is their situation?_ They are the most part of the thin Intestines or small Guts, _viz._ the _Duodenum_, the _Jejunum_, and the _Ileon_, which have their Residence in the middle, where they are encircled with a Portion of the two great Guts, _Cæcum_ and _Colon_, that take possession of the Sides, otherwise call'd the Flanks. The Reins or Kidneys are also in this Place, above, and somewhat backward. _What Parts are there contain'd in the _Hypogastrium_, and of what Place are they possest?_ The greater part of the thick-Guts, _Coecum_, and _Colon_, are enclos'd therein, with the entire _Rectum_; there is also a Portion of the _Ileon_, which hides it self in the sides of the _Ilia_, or Hip-Bones: In the middle under the _Os Pubis_, the Bladder is situated on the Gut _Rectum_ in Men, and the _Matrix_ in Women lies between the _Rectum_ and Bladder. _After what manner is the opening of a Corps or dead Body perform'd at a publick Dissection?_ {68} It is begun with a Crucial Incision in the Skin from underneath the Throat downward, traversing from one side to another in the Umbilical Region; then this Skin is pull'd off at the four Corners, and the _Panicula Adiposa_ is immediately discover'd: Under this Fat lies a Fleshy Membrane, call'd _Membrana Carnosa_; and after that, the common Membrane of all the Muscles of the lower Belly. Thus we have taken a View of what Anatomists commonly term the _five Teguments_, that is to say, the _Epiderma_ or Scarf-Skin, the _Derma_ or true Skin, the _Panicula Adiposa_, the _Panicula Carnosa_ or _Membranus Carnosa_, and the common Membrane of the Muscles. The five Teguments being remov'd, we meet with as many Muscles on each side, _viz._ the descending Oblique, the ascending Oblique, the Transverse, the streight, and the Pyramidal, by the means whereof the Belly is extended and contracted. Afterwards appears a Membrane nam'd _Peritonæum_, which contains all the Bowels, and covers the whole lower Belly, being strongly fasten'd to the first and third _Vertebra's_ of the Back. The Fat skinny Net which lies immediately under the _Peritonæum_, is call'd _Epiploon_ and _Omentum_, or the Caul; it floats over the Bowels, keeping them in a continual Suppleness necessary for their Functions, maintains the Heat of the Stomach, and contributes to Digestion. It remains to take an Account of the Bowels _viz._ the Stomach, Mesentery, Liver, Spleen, Kidneys, Bladder, and Guts, together with the Parts appointed for Generation, which in Men {69} are the Spermatick Vessels, the Testicles, and the _Penis_; and in Women, the Spermatick Vessels, the Testicles or Ovaries, the _Matrix_, and its _Vagina_ or Neck. _What is the Stomach?_ It is the Receptacle of the Aliments or Food convey'd thither thro' the _Oesophagus_ or Gullet, which is a Canal, or kind of streight Gut that reacheth from the Throat to the Mouth of the Stomach. The Stomach it self is situated immediately under the _Diaphragm_ or Midriff, between the Liver and the Spleen, having two Orifices, whereof the Left is properly call'd _Stomachus_, or the Upper, and the Right (at its other Extremity) _Pylorus_, or the lower Orifice. Its Figure resembleth that of a Bag-Pipe, and the greater part of its Body lies toward the Left side. It is compos'd of three Membranes, _viz._ one Common, which it receives from the _Peritonæum_; and two Proper; the two uppermost being smooth, and the innermost altogether wrinkled. _What is the _Pancreas_ or Sweet-bread?_ It is a Fat Body, consisting of many Glandules wrapt up in the same Tunicle, being situated under the _Pylorus_ or lower Orifice of the Stomach: It helps Digestion, and hath divers other uses; but its principal Office is to separate the serous Particles of the Blood, to be convey'd afterward into the Gut _Duodenum_, by a Canal or Passage, nam'd the _Pancreatick_. This Juice serves to cause the Chyle to ferment with the Choler, in order to remove the grosser Particles from those that ought to enter into the Lacteal Vessels. _Into how many sorts are the Guts distinguish'd?_ {70} There are two sorts, _viz._ the thin and the thick. _How many thin or small Guts are there?_ Three; that is to say, the _Duodenum_, the _Jejunum_, and the _Ileon_. _How many thick Guts are there?_ Three likewise; _viz._ the _Coecum_, the _Colon_, and the _Rectum_. _Why are some of them call'd thin Guts, and others thick?_ Because the thin are smaller, being appointed only to transport the Chyle out of the Stomach into the Reserver; whereas the thick are more large and stronger, serving to carry forth the gross Excrements out of the Belly. _Are the six Guts of an equal length?_ No, the _Duodenum_, which is the first of the thin Guts, is only twelve Fingers breadth long. The _Jejunum_, being the second, so call'd because always empty, is five Foot long: The third is nam'd _Ileon_, by reason of its great Turnings which oblige it to pass to the _Os Ilion_, where it produceth a Rupture; it extends it self almost twenty Foot in length. The first of the thick Guts, known by the Name of _Coecum_, is very short, and properly only an _Appendix_ or Bag of a Finger's length. That which follows is the _Colon_, being the largest of all, and full of little Cells, which are fill'd sometimes with Wind and other Matters that excite the Pains of the Colick. It encompasseth the thin Guts, in passing from the top to the bottom of the Belly, by the means of its great Circumvolutions, and is from eight to nine Foot long. The last is the _Rectum_ or {71} streight Gut, so nam'd, because it goes directly to the Fundament: It is no longer than ones Hand, but it is fleshy, and situated upon the _Os Sacrum_, and the _Coccyx_ or Rump-Bone. _What is the _Peristaltick_ Motion of the Guts?_ It is the successive Motion and Undulation, whereby the Guts insensibly push forward from the top to the bottom, the Matters contain'd in them; and that Motion which on the contrary is perform'd from the bottom to the top, is term'd the _Antiperistaltick_ as it happens in the _Iliack_ Passion, or twisting of the Guts, call'd _Domine Miserere_, by reason of its intolerable Pain. _What is the Mesentery?_ It is a kind of Membrane somewhat fleshy, which is join'd to the Spine in the bottom and middle of the Belly, and by its folding, keeps all the Guts steady in their place; it is all over beset with red, white, and Lymphatick Vessels; that is to say, those that carry the Blood, Chyle, and _Lympha_, which serves to cause this last to run more freely, and to ferment. Three notable Glandules are also observ'd therein, the greatest whereof lies in the middle, and is nam'd _Asellius's Pancreas_; the two other lesser are call'd _Lumbar_ Glandules, as being situated near the Left Kidney. From each of these Glandules proceeds a small Branch; and both are united together to make the great _Lacteal_ Vein, or _Thoracick_ Canal. This Tube conveys the Chyle along the _Vertebra's_ of the Back to the Left _Subclavian_ Vein; from whence it passeth into the ascending _Vena Cava_, and descends in the Right Ventricle of the Heart, {72} where it assumes the form of Blood; from whence it passeth to the Lungs thro' the _Pulmonary_ Artery; then it returns to the Heart thro' the _Pulmonary_ Vein, and goes forth again thro' the Left Ventricle of the Heart, between the _Aorta_ or great Artery, to be afterward distributed to all the Parts of the Body. This is the ordinary Passage for the Circulation of the Chyle, and the Sanguification of the Heart. _What is the Liver?_ The Liver, being the thickest of all the Bowels, is plac'd in the Right _Hypochondrium_, at the distance only of a Fingers breadth from the Diaphragm; its Figure much resembling that of a thick piece of Beef: It is Convex on the outside, and Concave within; its Substance is soft and tender, its Colour and Consistence being like coagulated Blood: It is cleft at bottom, and divided into two Lobes, _viz._ one greater, and the other less: Its Office is to purifie the Mass of Blood by Filtration; and it is bound by two strong Ligaments, the first whereof adheres to the Diaphragm, and the second to the _Xiphoides_ or Sword-like Cartilage. Two great Veins take their Rise from hence, _viz._ the _Vena Portæ_, and the _Vena Cava_, which form innumerable Branches, as it were Roots in the Body of the Liver. The Gall-Bladder is fasten'd to the hollow part thereof, and dischargeth its Choler into the Gut _Duodenum_, thro' the Vessels that bear the Name of _Meatus Choledochi_, or _Ductus Biliares._ This Choler is not a meer Excrement, but on the contrary of singular Use in causing the Fermentation of the Chyle, and bringing it to perfection. {73} _What is the Spleen?_ The Spleen is a Bowel resembling a Hart's Tongue in shape, and situated in the Left _Hypochondrium_, over-against the Liver: Its length is about half a Foot, and its breadth equal to that of three Fingers; its Substance being soft, as that of the Liver, and its Colour like dark coagulated Blood: It is fasten'd to the _Peritonæum_, Left Kidney, Diaphragm, and to the Caul on the inside; as also to the Stomach by certain Veins, call'd _Vasa Brevia_; nevertheless these Ligatures do not hinder it from wandering here and there in the lower Belly, where it often changeth its place, and causeth many dreadful symptoms by its irregular Motions. Its Office is to Subtilize the Blood by cleansing and refining it. _What are the Reins?_ The Reins or Kidneys are Parts of a Fleshy Consistence, harder and more firm than that of the Liver and Spleen: They are both situated in the sides of the Umbilical Region, upon the Muscle _Psoas_, between the two Tunicks of the _Peritonæum_; but the Right is lower than the Left: Their Shape resembleth that of a _French_ Bean, and they receive Nerves from the Stomach, whence Vomitings are frequently occasion'd in the Nephritical Colicks: They are fasten'd to the Midriff, Loins, and _Aorta_, by the _Emulgent_ Arteries; as also to the Bladder by the _Ureters_. The Right Kidney likewise adheres to the Gut _Cæcum_, and the Left to the _Colon_. Their Office is to filtrate or strain the Urine in the _Pelves_ or Basons, which they have in the middle of their Body on the inside, and {74} to cause it to run thro' the Vessels call'd _Ureters_ into the Bladder. Immediately above the Reins on each side, is a flat and soft Glandule, of the thickness of a Nut; they are nam'd _Renal Glandules_, or _Capsulæ Atribiliariæ_, because they contain a blackish Liquor, which (as they say) serves as it were Leaven for the Blood, to set it a fermenting. _What is the Bladder?_ It is the Bason or Reserver of Urines, of a Membranous Substance as the Stomach, being plac'd in the middle of the Hypogastrick Region; so that it is guarded by the _Os Sacrum_ behind, and by the _Os Pubis_ before: Two Parts are to be distinguish'd therein, _viz_. its Bottom and Top; by its Membranous Bottom it is join'd to the Navel, and suspended by the means of the _Urachus_, and the two Umbilical Arteries which degenerate into Ligaments in adult Persons: As by its fleshy Neck, longer and crooked in Men, and shorter and streight in Women it cleaves to the _Intestinum Rectum_ in the former, and to the Neck of the Womb in the latter. Lastly, its Office is to receive the Urines to keep them, and to discharge them from time to time. _What are the Genitals in Men?_ They are the Spermatick Vessels, the Testicles, and the _Penis_. The Spermatick Vessels are a Vein and an Artery on each side; the former proceeding from the _Aorta_, or thick Artery of the Heart; and the other from the Branches of the _Vena Cava_ of the Liver. These Arteries and Veins are terminated in the Body of the {75} Testicles, which are two in Number, enclos'd within the _Scrotum_. The Office of the Testicles is to filtrate the Seed, which is brought thither from all the parts of the Body, thro' the Spermatick Vessels, called _Præparantia_, and afterwards to cause it to pass thro' others nam'd _Deferentia_, to the _Vesiculæ Seminales_, from whence it is forc'd into the _Ureter_, thro' two small and very short Canals. The _Penis_ or Yard is a Nervous and Membranous Part, well furnish'd with Veins and Arteries, containing in the middle the Canal of the _Ureter_: Its Extremity, which consists of a very delicate and spongy sort of Flesh, is call'd _Balanus_, or _Glans_, and the Nut, the Skin that covers it being nam'd the _Præputium_, or the Fore-Skin. Thus by the means of this swell'd Part, and stiff thro' the affluence of the Spirits, the Male injects his Seed into the _Matrix_ of the Female, to propagate his Kind. _What are the Parts appropriated to Generation in Women?_ They are the Spermatick Vessels, the Ovaries or Testicles, and the _Matrix_. The Spermatick Vessels are a Vein and an Artery on each side, as in Men: The Ovaries or Testicles, situated on the side of the bottom of the _Matrix_, are almost of the same bigness with those of Men, but of a round and flat Figure. The _Vesiculæ_, or little Bladders which they contain, are usually term'd _Ova_ or Eggs by Modern Anatomists; and the Vessels that pass from these Testicles or Ovaries to the _Cornua_ of the _Uterus_, are call'd _Deferentia_ or _Ejaculatoria_. {76} The _Matrix_, _Uterus_ or Womb, is the principal Organ of Generation, and the place where it is perform'd, resembling the Figure of a Pear with its Head upward, and being situated between the Gut _Rectum_ and the Bladder: It is of a fleshy and membranous Substance, retain'd in its place by four Ligaments, fasten'd to the bottom; whereof the two upper are large ones, proceeding from the Loins, and the two lower round, taking their Rise from the Groin, where they form a kind of Goose-Foot, which is extended to the _Os Pubis_, and the flat part of the Thighs; which is the cause that Women are in danger of Miscarrying when they fall upon their Knees. The Exterior Neck of the Womb, call'd _Vagina_, is made almost in form of a Throat or Gullet, extending it self outwardly to the sides of the Lips of the _Pudendum_, and being terminated inwardly at the internal Orifice of the _Matrix_, the shape whereof resembleth that of the Muzzle or Nose of a little Dog. The outward Neck of the womb is fasten'd to the Bladder and the _Os Pubis_ before, and in the hinder part to the _Os Sacrum_: Between the Lips of the _Pudendum_ lie the _Nymphæ_, which are plac'd at the Extremity of the Canal of the Bladder, to convey the Urines; and somewhat farther appear four Caruncles, or small pieces of Flesh, at the Entrance of the _Vagina_, which when join'd together make the thin Membrane call'd _Hymen_. * * * * * {77} CHAP. XIV. _Of the Anatomy of the _Thorax_, Breast, or middle _Venter_._ _What is the Breast?_ It is a Cavity in which the Heart and the Lungs are principally enclos'd. _What is to be consider'd outwardly in the Breast?_ Its extent, and the situation of the Parts therein contain'd. _What is its extent?_ It is extended from the _Clavicles_ to the _Xiphoides_, or Sword-like Cartilage on the fore-part, and bounded on the hinder by the twelfth _Vertebra_ of the Back, having all the Ribs to form its Circumference, and the Diaphragm for its Bounds at bottom, separating it from the _Abdomen_ or lower Belly. _What is the situation of the Parts contain'd in the Breast?_ The Lungs take up the upper Region, and fill almost the whole Space, descending at the distance of two Fingers breadth from the Diaphragm; the Heart is situated in the middle, bearing its Point somewhat towards the Left side, under the Lobes of the Lungs, which are divided by the _Mediastinum_ that distinguishes them into the Right and Left Parts. _How is the Breast Anatomiz'd or open'd?_ {78} After the dissection of the five Teguments, and the removal of the Muscles, as in the lower Belly, the Anatomist proceeds to lift up the _Sternum_ or Breast-Bone, by separating it from the Ribs; then it is laid upon the Face, or else entirely taken away, to the end that the internal Parts of the Breast may be more clearly discover'd; whereupon immediately appear, the Heart, the Lungs, the Diaphragm, and the _Mediastinum_, which sticks to the _Sternum_ throughout its whole length. _What is the Heart?_ It is a most noble Part, being the Fountain of Life, and the first Original of the Motion of all the others; on which account it is call'd _Primus vivens_, & _ultimum moriens_; that is to say, the first Member that begins to live, and the last that dies. _What Parts are to be consider'd in the Heart?_ Its fleshy Substance, with all its Fibres turn'd round like the Skrews of a Vice; its _Basis_, Point, Auricles, Ventricles, large Vessels, _Pericardium_ and Ligatures or Tyes: The _Basis_ is the uppermost and broadest part; the Point is the lowermost and narrowest part; the two Auricles or small Ears being as it were little Cisterns or Reservers, that pour the Blood by degrees into the Heart, are situated on each side above the Ventricles. The Ventricles, which are likewise two in Number, are certain Cavities in its Right and Left Sides. The large Vessels are the _Aorta_ or great Artery, and the _Vena Cava_ together with the Pulmonary Artery and Vein. The _Pericardium_ is a kind of Bag fill'd with Water, wherein the Heart is kept; which is {79} fasten'd to the _Mediastinum_ by its _Basis_, and to the large Vessels that enter and go out of its Ventricles. _What are the Terms appropriated to the continual beating of the Heart?_ They are _Diastole_ and _Systole_, from whence proceed two several Motions, the first whereof is that of Dilatation, and the other of Contraction, communicated to all the Arteries which have the same Pulse. _To what use serves the Water contain'd in the _Pericardium_?_ It prevents the drying of the Heart by its perpetual Motion. _What are the Lungs?_ They are an Organ serving for Respiration, of a soft Substance, and porous as a Sponge, being all over beset with Arteries, Veins, Nerves, and Lymphatick Vessels, and perforated with small Cartilaginous Tubes, that are imparted to it from the Wind-Pipe, and are call'd _Bronchia_. Their Natural Colour is a pale Red, and marbl'd dark Brown; and their whole Body is wrapt up in a fine smooth Membrane, which they receive from the _Pleuron_. They are suspended by the Wind-Pipe, by their proper Artery and Vein, and by the Ligatures that fasten them to the _Sternum_, _Mediastinum_, and frequently to the _Pleuron_ it self: They are also divided into the Right and Left Parts by the _Mediastinum_; having four or five Lobes, whereof those on the Left side cover the Heart. Their continual Motion consists in _Inspiration_, to take in the Air, and _Expiration_, to drive it out. The _Larynx_ makes the Entrance of the Wind-Pipe {80} into the Lungs, and the _Pharynx_ that of the _Oesophagus_ or Gullet, at the bottom of the Mouth to pass into the Stomach. * * * * * CHAP. XV. _Of the Anatomy of the Head, or upper _Venter_._ _What is the head?_ It is a bony Part, that contains and encloseth the Brain within its Cavity. _What is most remarkable in the outward parts of the Head?_ The Temporal Arteries, the _Crotaphitæ_, or Temporal Muscles, and the Sutures of the Skull. _Why are these things considerable?_ The Temporal Arteries are of good Note, because they are expos'd on the outside, lying even with the Skin. The _Crotophite_ Muscles are so likewise, in regard that they cannot be hurt without danger of Convulsions, by reason of the _Pericranium_ with which they are cover'd. And the Sutures, because the _Meninges_ of the Brain proceed from thence to form the _Pericranium._ _What is the _Pericranium_?_ It is a Membrane that lies under the thick hairy Skin of the Head, and immediately covers the Skull. _What are the _Meninges_?_ They are two Membranes that enclose the Substance or Marrow of the Brain. _What is a Suture?_ {81} It is a kind of thick Seam or Stitch, that serves to unite the Bones of the Skull. _How many sorts of Sutures are there?_ There are two sorts, _viz._ the true, and the false or Bastard. _What are the true Sutures?_ They are three in number, namely the _Sagittal_, the _Coronal_, and the _Lambdoidal._ _What is the disposition or situation of the true Sutures?_ The _Sagittal_ is streight, beginning in the middle of the Fore-head, and sometimes at the root of the Nose, and being terminated behind, at the joining of the two Branches of the _Lambdoidal Suture_. The Coronal appears in form of a Crown, passing to the middle of the Head, and descending thro' the Temples, to finish its Circumference in the Root of the Nose. The _Lambdoidal_ Suture is made like an open Pair of Compasses, the Legs whereof are extended toward the Shoulders; and the Button is in the top of the Head backward. _What are the Bastard Sutures?_ They are those that are call'd _Squamous_ or scaly. _What is the disposition of natural situation of these false Sutures?_ They are plac'd at the two sides of the Head, and make a Semi-Circle of the bigness of the Ears, round the same Ears. _What difference is there between the true and spurious Sutures._ The true Sutures are made in form of the Teeth of a Saw, which enter one into the other; and the false or Bastard ones are those that resemble the Scales of Fishes, which {82} are join'd together by passing one over the other. _What is the Use of the Sutures?_ The Ancients were of Opinion, that they were made to hinder the Fracture of one Skull-Bone from passing thro' the whole Head; but there is more reason to believe that they have the three following Uses, that is to say, 1. To promote the transpiration of the Brain. 2. To give Passage to the Vessels that go to the _Diploe_. 3. To retain the _Meninges_, and to support the Mass of the Brain, which is cover'd by them. _What are the Names of the Bones that compose the Skull?_ The Bone of the fore-part of the Head is call'd _Sinciput_, or the Fore-head-Bone, as also the _Frontal_ or _Coronal_ Bone. The Bone of the hinder-part, enclos'd within the _Lambdoidal_ Suture, is term'd the _Occipital._ The two Bones that form the upper-part, and are distinguish'd by the Sagittal Suture, bear the Name of _Parietals_, one being on the Right side, and the other on the Left. And those behind the Ears are call'd _Temporal_, _Squamosa_, or _Petrosa_. These also are distinguish'd into the Right and Left Temporals, and are join'd to the bottom of the Parietal by a bastard squamous Suture. _What is most remarkable in the thickness of the Skull-Bones?_ The _Diploe_, which is nothing else but a _Plexus_ or Contexture of small Vessels, that nourish the Bones, and in the middle of their thickness make the distinction of the first and second Tablature of the Bones; whence it sometimes {83} happens that an exfoliative Trepan, or Semi-Trepan, is sufficient, when the first of these two Tables is only broken, the other remaining entire. _Is the Brain which is preserv'd in the Skull all of one Piece, or one equal Mass?_ No, it is distinguish'd by the means of the _Meninges_ into the Brain it self, and the _Cerebellum_ or little Brain; the Brain, properly so called, takes up almost the whole Cavity of the Skull, and the _Cerebellum_ is lodg'd altogether in the hinder-part, where it constitutes only one entire Body; whereas the former is divided into the Right and Left Parts by the _Meninges_, which cut it even to the bottom; whence these Foldings are call'd _Falx_; i. e. a _Scythe_ or _Sickle_. _What is chiefly remarkable in the Substance of the Brain?_ The Ventricles or Cavities which are found therein, together with the great Number of Veins, Arteries, Lymphatic Vessels, and Nerves, that carry Sense to all the Parts of the Body, and Spirits for their Motion. _An exact Historical Account of all the Holes of the Skull, and the Vessels that pass thro' them._ To attain to an exact Knowledge of all the Holes with which the inside of the _Basis_ of the Skull is perforated, they are to be consider'd either with respect to the Nerves, or to the Sanguinary Vessels. {84} There are nine Pairs of Nerves that arise from the _Medulla Oblongata_, and go forth out of the Skull through many Holes hereafter nam'd. The first Pair is that of the _Olfactory_ Nerves, appropriated to the Sense of Smelling, which are divided below the _Os Cribiforme_, or Sieve-like Bone, into divers Threads, that passing into the Nose through many Holes with which this Bone is pierc'd, are distributed to the inner Tunick of the Nose. The second Pair is that of the _Optick_ or Visual Nerves, that pass into the Orbits of the Eyes, thro' certain peculiar Holes made in the _Os Sphenoides_, or Wedge-like Bone, immediately above the _Anterior Apophysis Clinoides_. In the Portion of the _Os Sphenoides_, that makes the _Basis_ of the Orbit, lies a Fissure about seven or eight Hairs breadth long, which is to be observ'd chiefly at the bottom, that is to say, below the Hole, thro' which the Optick Nerve passeth; where it is almost round, and larger than at the top, where it is terminated in a very long and acute Angle. There are many Pairs of Nerves that enter into the Orbit thro' this Fissure, _viz._ 1. The third Pair, call'd the _Motorii Oculorum_. 2. The fourth Pair, nam'd _Pathetici_, by Dr. _Willis_. And 3. The whole sixth Pair. Besides these three Pairs, which go entire thro' this Cleft, there is also a Passage for the upper Branch of the foremost Fibre of the fifth Pair, which the same renowned Physician calls the _Ophthalmick_ Branch. Beyond the lower-part of the said Fissure, toward the hinder-part of the Head, is to be seen {85} in the _Os Sphenoides_ on each side, a Hole that doth not penetrate the _Basis_ of the Skull, but makes a kind of _Ductus_, about an Hair's breadth long, which is open'd behind the Orbit on the top of the Space between the _Apophysis Pterygoides_, and the third Bone of the Jaw; thro' this _Ductus_ runs the lower Branch of the foremost Fibre of the fifth Pair. About the length of two Hairs breadth beyond these _Ductus's_, we may also discover in the _Os Sphenoides_, or Wedge-like Bone, two Holes of an Oblong and almost Oval Figure, which are plac'd in the hindermost sides of that of the _Os Sphenoides_, and gives passage to the hindermost Fibre of the fifth Pair. The Hole thro' which runs the _Auditory_ Nerve, that makes the seventh Pair, is in the middle of the hinder-part of the _Os Petrosum_, that looks toward the _Cerebellum_: This Hole being very large, is the Entrance of a _Ductus_ that is hollow'd in the _Os Petrosum_, and which sinking obliquely from the fore-part backward, for the depth of about two Hairs breadth, forms as it were the bottom of a Sack, the lowermost part whereof is terminated partly by the _Basis_ of the _Cochlea_, and partly by a Portion of the Mouth of the _Vestibulum_. At the bottom of this _Ductus_ are many Holes, but the most considerable is that of the upper-part, thro' which passeth a Portion of the Auditory Nerve. This is also the Entrance of another _Ductus_ made in the _Os Petrosum_, which is open'd between the _Apophysis Mastoides_ and _Styloides_: These other Holes afford a Passage to the Branches of the soft Portion of the same Auditory Nerve. {86} Below this _Ductus_ there is a remarkable Hole form'd by the meeting of two hollow Cuts the larger whereof is in the Occipital Bone and the other in the lower-part of the _Apophysis Petrosi_: From the middle of the upper-part of this Hole issueth forth a small Prominence or bony Point, whereto is join'd an Appendix of the _Dura Mater_, which divides the Hole into two parts; so that thro' the foremost Orifice passeth the Nerve of the eighth Pair, and that which is call'd the _Spinal_ Nerve. We shall have occasion hereafter to shew the Use of the hinder Orifice. Near the great Hole of the Occipital Bone from whence proceeds the _Medulla Oblongata_, we may observe a Hole almost round and oblong thro' which passeth the Nerve of the ninth Pair. This Hole is entirely situated in the Occipital Bone, and making a little Way in the Bone passeth obliquely from the back-part forward. In the inside of the Skull this Hole is sometimes double, but its two Entrances are re-united in the outward-part of the Skull; and the two Branches that form the Origine of this Nerve and which pass thro' these two Holes, are likewise re-united at their Departure, These are the Passages of the nine Pairs of Nerves that proceed from the _Medulla Oblongata_, and it remains only to show that Paths thro' which the Intercostal Nerve goes forth, as also that of the tenth Pair. The Intercostal runs out of the Skull thro' the _Ductus_ that gives Entrance to the Internal _Carotick_ Artery. As for the tenth Pair, in regard that it ariseth from the Marrow which is enclos'd between the Occipital {87} Bone and the first _Vertebra_, it goes forth thro' the Hole of the _Dura Mater_, where the Vertebral Artery enters. To know well the Holes thro' which the Vessels that belong to the inner-part of the Head enter, and issue forth, it is requisite to distinguish them into those which are distributed to the _Dura Mater_, and those that are appointed for the Brain. The Vessels of the _Dura Mater_, are Branches of the _Carotick_ or Vertebral Arteries. In the _Os Sphenoides_, or Wedge-like Bone, behind the Hole thro' which passeth the hindermost Fibre of the fifth Pair of Nerves lies another small Hole, almost round, that gives Entrance to a Branch of the _External Carotick_ Artery, which in entring, immediately adheres to the _Dura Mater_, and forms many Ramifications to overspread the whole Portion of this Membrane, which covers the sides, and the upper-part of the Brain. At the bottom and top of the lateral outward part of the Orbit of the Eye, above the acute Angle, for want of the _Os Sphenoides_, there is a Hole thro' which passeth an Artery, being a Twig of a Branch of the _Internal Carotick_, which is diffus'd in the Eye, and distributed to almost the whole Portion of the _Dura Mater_, that covers the fore-part of the Brain. The Vertebral Artery in entring into the Skull, furnisheth it on each side with a considerable Branch, which is dispers'd throughout the whole Portion of the _Dura Mater_ that covers the _Cerebellum_. {88} As for the Veins that accompany these Arteries, they almost all go out of the Skull thro' the same Holes where the other enters. There are four thick Arteries which convey to the Brain the Matter with which it is nourish'd, and that whereof the Spirits are form'd, _viz._ the two _Internal Caroticks_, and the two _Vertebrals._ The _Internal Carotick_ Arteries enter into the Skull thro a particular _Ductus_ made in the Temporal Bone, the Mouth thereof being of an Oval Figure and situated in the outward part of the _Basis_ of the Skull, before the Hole of the _Internal Jugular._ This _Ductus_ extends it self obliquely from the back-side forward, and after having made about three Hairs breadth in length, is terminated in the hinder-part of the _Os Sphenoides_. The Artery traverseth the whole winding Compass of this _Ductus_, which resembles the Figure of the _Roman_ Letter S, and at the Mouth of the same _Ductus_ runs under the _Dura Mater_ along the sides of the _Os Sphenoides_ to the _Anterior Apophyses Clinoides_, where it riseth up again, to perforate the _Dura Mater_, and to adhere to the Root of the Brain. These Vessels, in like manner, after their departure from the Bone of the Temples to the place where they pierce the _Dura Mater_, make a second Circuit in form of the _Roman_ Character S. At the place where these _Carotick_ Arteries penetrate the _Dura Mater_, they send forth a thick Branch, which enters into the Orbit of the Eye, by the lower-part of the Hole, thro' which the _Optick_ Nerve hath its Passage. {89} The _Vertebral_ Arteries proceeding from the Holes of the transverse _Apophyses_ of the first _Vertebra_, turn about in passing under the upper oblique _Apophyses_ of the seven _Vertebra's_: Afterward they perforate the _Dura Mater_, and running under the Marrow, enter into the Skull thro' the Occipital Hole; then inclining one toward another, they are re-united, and form only one single Trunk. The Veins that bring back the Blood from the Substance of the Brain, are emptied into the _Sinus's_ of the _Dura Mater_, which are all discharg'd into those that are call'd _Lateral_, which last go out of the Skull immediately under the Nerves of the eighth Pair, thro' the hinder-part of the Hole made by the meeting of the _Occipital_ Bone, and the _Apophysis Petrosa_. These Lateral _Sinus's_ fall into the _Internal Jugulars_, which are receiv'd into a considerable Sinking hollow'd on each side in the outward, part of the _Basis_ of the Skull, which is nam'd the Pit or Hole of the _Internal Jugular_. In the upper and hinder-part of the Hole, from whence the lateral _Sinus's_ issue forth, is to be seen an opening in the Extremity of a _Ductus_, the Mouth whereof lies behind the _Condyli_, which are on the sides of the Occipital Trunk: This _Ductus_ is extended about the length of two Hairs breadth in the Bone, and the Canal enclos'd therein is open'd immediately into the _Vertebral Sinus_: So that one might affirm it to be as it were its Original Source. Whence it appears that the Blood contained in the lateral _Sinus's_ is emptied thro' two places; the greater Portion thereof descending in the _Jugulars_ {90} from the Neck, and the other in the _Vertebral Sinus's_: Sometimes those _Ductus's_ are four only on one side, another while both are stopt up, and the Blood contain'd in the lateral _Sinus's_ is discharg'd into the _Internal Jugulars_. Behind the _Apophysis Mastoides_ on each side is a remarkable Hole, thro' which passeth a thick Vein, which brings back part of the Blood that hath been distributed to the Teguments and Muscles, which cover part of the _Occiput_ or hinder-side of the Head: This Vein is open'd into the lateral _Sinus's_ at the place where they begin to turn about. But in the Heads of some Persons, this Hole is found only on one side, and even sometimes not at all, in which case the Blood contain'd in the Vessels falls into the _External Jugulars_, with which the Branches of this Vein have a Communication. In each _Parietal_ Bone on the side of the _Sagittal_ Suture, at a little distance from the _Lambdoidal_, appears a Hole, thro' which passeth a Vein, that brings back the Blood of the Teguments of the Head, and dischargeth it self into the upper _Longitudinal Sinus_. These Holes are sometimes on both; and then the Blood contain'd in the Branches of this Vein runs into the _External Jugulars_. In the middle of the _Sella_ of the _Os Sphenoides_, we may observe one or two small Holes thro' which (according to the Opinion of some Modern Anatomists) the _Lympha_ contain'd in the _Glandula Pituitaria_ is thrown {91} into the _Sinus_ of the edge of the _Os Sphenoides_; nevertheless it is certain, that these Holes are fill'd only with Sanguinary Vessels, which carry and bring back the Blood of the Bones and Membranes, whereof those _Sinus's_ are compos'd; besides that, these Holes are rarely found in adult Persons. Between the Spine of the _Coronal_ Suture and the _Crista Galli_, is a Hole which serves as an Entrance for a _Ductus_, which sinks from the top to the bottom, the length of about two Hairs breadth in the thickness of the inner Table of the _Coronal_: The Root of the upper _Longitudinal Sinus_ is strongly implanted in this Hole, which also affords a Passage to some Sanguinary Vessels appointed for the Nourishment of this inner Table. Many other small Holes are found in divers places of the _Basis_ of the Skull; the chief whereof are those that are observ'd in the _Apophysis Petrosa_, and give Passage to a great number of Vessels that serve for the Nutriment of that part of the Temporal Bone which is call'd the _Tympanum_, or Drum: The other Holes are principally design'd for the Vessels that are serviceable in the nourishing of divers parts of the _Basis_ of the Skull. _After what manner is the opening of the Head or Skull perform'd?_ It is done by sawing it asunder round about and above the Ears; then it is taken off, after having before cut off the Hair, and made a Crucial Incision in the Skin from the fore-part to the hinder, and from one Ear to the other; as also after having {92} pull'd off and laid down the four Corners to the bottom. _How is the Brain anatomiz'd?_ It is done by cutting it Superficially, and by Leaves, in order to discover by little and little the Ventricles, Vessels, and Nerves, with their Original Sources, &c. Or else it is taken entire out of the Skull, (the Nerves having been before examin'd) and laid down; so that without cutting any thing, all the parts of the Brain may be set in their proper places, to find out those that are sought for. * * * * * {93} A TREATISE OF _Straps, Swathing-Bands, Bandages, Bolsters, Splints, Tents, Vesicatories, Setons, Cauteries, Leeches, Cupping-Glasses, and Phlebotomy._ * * * * * CHAP. XVI. _Of Straps, Swathing-Bands, Bandages, and Bolsters._ _What is a Strap?_ It is a kind of Band commonly made use of for the Extension of the Members in the reducing of Fractures and Luxations; or else in binding Patients, when it is necessary to confine them, for the more secure performing of some painful Operation: These sorts of Ligatures have different Names, {94} according to their several Uses, and often bear that of their Inventer. _What is the Matter whereof these Straps are compos'd?_ They may be of divers sorts, but are usually made of Silk, Wooll, or Leather. _What is a Swathing-Band?_ It is a long and broad Band, that serves to wrap up and contain the Parts with the Surgeons Dressings or Preparatives. _Of what Matter are these Swathing-Bands made?_ They are made at present of Linnen-Cloth but in the time of _Hippocrates_, were made of Leather or Woollen-Stuff. _How many sorts of Swathing-Bands are there in general?_ There are two sorts, _viz._ the Simple and Compound; the former are those that are smooth, having only two ends; and the other are those which are trimm'd with Wooll, Cotton, or Felt, or that have many Heads, that is to say, Ends, fasten'd or cut in divers places according as different Occasions require. _What are the Conditions requisite in the Linen-Cloth, whereof the Swathing-Bands are made?_ It must be clean, and half worn out, not having any manner of Hem or Lift. _What are the Names of the different Swathing-Bands?_ There are innumerable, but the greater part them take their Denominations from their Figure or Shape; as the Long, Streight, Triangular, and those which have many Heads, or are trimm'd. {95} _What is A Bandage?_ It is the Application of a Swathing-Band to any Part. _How many sorts of Bandages are there?_ As many as there are different Parts to be bound; some of them being Simple, and others Compound: The former are those that are made with an uniform Band; as the Bandage call'd the _Truss_, and divers other sorts: The Compound are those that consist of many Bands set one upon another, or sew'd together; or else those that have many Heads. They have also particular Names taken from the Inventers of them, or from their Effect; as _Expulsive_ Bandages to drive back, _Attractive_ to draw forward, _Contentive_ to contain, _Retentive_ to restrain, _Divulsive_ to remove, _Agglutinative_ to rejoin, &c. There are others whereto certain peculiar Names are appropriated; as _Bridles_ for the lower Jaw, _Slings_ for the Chin, the back part of the Head, Shoulder, and _Perinæum_; _Scapularies_ for the Body, after the manner of the Scapularies of Monks; _Trusses_ for Ruptures; _Stirrups_ for the Ankle-Bones of the Feet, in letting Blood, and upon other Occasions. Lastly, there are an infinite Number of Bandages, the Structure whereof is learnt by Practice, in observing the Methods of able Surgeons, who invent them daily, according to their several Manners; and the first _Ideas_ of these can only be taken in reading Authors that have treated of them. _What are the general Conditions to be observ'd in the Bandages?_ {96} There are many, _viz._ 1. Care must be taken that the Bands be roll'd firm, and that they be not too streight nor too loose. 2. They are to be untied from time to time in Fractures, they must also be taken away every three or four Days, to be refitted. 3. They must be neatly and conveniently roll'd, that the Patient may not be uneasie or disquieted. _What ought to be observ'd in fitting the Bolsters?_ Care must be taken to make them even, soft, and proportionable to the bigness of the Part affected; to trimm them most in the uneven places, that the Bands may be better roll'd over them, and to keep them continually moisten'd with some Liquor proper for the Disease as well as the Bands. _In treating of every Disease in particular, we shall shew the manner of making the particular Bandage that is convenient for it._ * * * * * {97} A TREATISE OF _Chirurgical Diseases_. * * * * * CHAP. I. _Of Tumours in general, Abcesses or Impostumes, Breakings out, Pustules, and Tubercles._ _What is a Tumour?_ A Tumour is a rising or bloated Swelling rais'd in some part of the Body by a Setling of Humours. _How is this setling of Humours produc'd?_ Two several ways, _viz._ by _Fluxion_ and _Congestion_. _What is the Setling by Fluxion?_ It is that which raiseth the Tumour all at once, or in a very little space of time, by the Fluidity of the Matter. {98} _What is the Setling by Congestion?_ It is that which produceth the Tumour by little and little, and almost insensibly, by reason of the slow Progress and thickness of the Matter. _Which are the most dangerous Tumours, those that arise from Fluxion, or those that derive their Original from Congestion?_ They that proceed from Congestion, because their thick and gross Matter always renders 'em obstinate, and difficult to be cur'd. _Whence do the differences of Tumours proceed?_ They are taken, _first_, from the Natural Humours, _Simple_, _Mixt_, and _Alter'd_: _Simple_, as the _Phlegmon_, which is made of Blood, and the _Erysipelas_ of Choler; _Mixt_, as the _Erysipelas Phlegmon_, which consists of Blood mingl'd with a Portion of Choler; or the _Phlegmonous Erysipelas_, which proceeds from Choler intermixt with a Portion of Blood: _Alter'd_, as the _Melia_ which is compos'd of many Humours, that can not be any longer distinguish'd by reason of their too great Alteration. _Secondly_, the difference of Tumours is taken from their likeness to some other thing, as the Carbuncle and the _Talpa_, the former resembling a burning Coal, and the other a Mole, according to the Etymology of their _Latin_ Names. _Thirdly_, From the Parts where they are situated; as the Ophthalmy in the Eye and the Quinsey in the Throat. _Fourthly_, from Disease that causeth 'em, as Venereal and Pestilential Buboes. _Fifthly_, from certain Qualities found in some, and not in others; as the _Encysted_ Tumours, which have their Matter clos'd within their proper _Cystes_ or Membranes, and so of many others. {99} _How many kinds of Tumours are there that comprehend at once all the particular Species?_ They are four in Number, _viz._ the Natural Tumours, the Encysted, the Critical, and the Malignant. _What are natural Tumours?_ They are those that are made of the four Humours contain'd in the Mass of the Blood, or else of many at once intermixt together. _What are the four Humours contain'd in the Mass of the Blood?_ They are Blood, Choler, Phlegm, and Melancholy, every one whereof produceth its particular Tumour: Thus the Blood produces the _Phlegmon_, Choler the _Erysipelas_, Phlegm the _Oedema_, and Melancholy the _Scirrhus._ The Mixture of these is in like manner the Cause of the _Erysipelatous Phlegmon_, the _Oedomatous Phlegmon_ or _Phlegmonous Erysipelas_, and the _Phlegmonous Oedema_, according to the quality of the Humours which are predominant, from whence the several Tumours take their Names. _What are the _Encysted_ Tumours?_ They are those the Matter whereof is contain'd in certain _Cystes_, or Membranous Bags; as the _Meliceris_, and the _Struma_ or Kings-Evil. _What are Critical Tumours?_ They are those that appear all at once in acute Diseases, and terminate them with good or bad Success. _What are Malignant Tumours?_ They are those that are always accompany'd with extraordinary and dreadful Symptoms, and whose Consequences are also very dangerous; as the Carbuncle in the Plague. {100} _What are Impostumes or Abcesses, Breakings out and Pustules?_ Indeed, it may be affirm'd, that all these kinds of Tumours scarce differ one from another, except in their size or bigness; nevertheless, to speak properly, by the Names of Impostumes or Abcesses are understood gross Tumours that are suppurable, or may be dissolv'd, and by those of Breakings out and Pustules, only simple Pusteal Wheals, or small Tumours, that appear in great Numbers, and which frequently do not continue to Suppuration; some of them consisting of very few Humours, and others altogether of dry Matter. _What difference is there between a Tumour and an Impostume or Abcess?_ They differ in this particular, that all Tumours are not Impostumes nor Abcesses; but there is no Impostume nor Abcess that is not a Tumour: As for Example, Wens and _Ganglions_ are Tumours, yet are not Abcesses nor Impostumes; whereas these last are always Tumours in regard that they cause Bunches and Elevations. * * * * * CHAP. II. _Of the general Method to be observ'd in the curing of Tumours_. _What ought a Surgeon chiefly to observe in Tumours, before he undertake their Cure?_ He ought to know three things, _viz._ 1. The Nature or Quality of the Tumour. 2. The {101} time of its formation and 3. Its situation: The Quality of the Tumour is to be known, because the Natural one is otherwise handl'd than that which is Encysted, Critical or Malignant. As for the time of its Formation, it is four-fold, _viz._ the Beginning, Increase, State, and Declination, wherein altogether different Remedies are to be apply'd. The Situation of the Tumour must be also observ'd, because the dressing and opening of it ought to be as exact as is possible, to avoid the meeting with an Artery or neighbouring Tendon. _How many ways are all the Tumours that are curable, terminated?_ They are terminated after two manners, _viz._ either by dissolving 'em, or by Suppuration. _Are not the_ Scirrhus _and the_ Esthiomenus _or Gangrene, two means that sometimes serve to terminate and cure Impostumes?_ Yes, but it is done imperfectly, in regard that a Tumour or Impostume cannot be said to be absolutely cur'd, as long as there remains any thing of the Original Malady, as it happens in the _Scirrhus_, where the Matter is harden'd by an imperfect dissolving of it, or when the Impostume degenerates into a greater and more dangerous Distemper, as it appears in the _Esthiomenus_ or Gangrene that succeeds it. _Which is the most effectual means of curing Impostumes, that of dissolving, or that of bringing them to Suppuration?_ That of dissolving 'em is without doubt the most successful, and that which ought to be us'd as much as is possible; nevertheless some Cases are to be excepted, wherein the Tumours {102} or Abcesses are Critical and Malignant; for then the way of Suppuration is not only preferable, but must also be procur'd by all sorts of means, even by opening; which may be done upon this occasion, without waiting for their perfect Maturity. _What are the Precautions whereto a Surgeon ought to have regard before he undertake the opening of Tumours?_ He must take care to avoid cutting the Fibres of the Muscles, and in great Abcesses, to cause all the corrupt Matter to be discharg'd at once, to prevent the Patient's falling into a Swoon. _Ought the opening of Tumours always to be made longitudinally, and according to the direct Course of the Fibres?_ No, it is sometimes necessary to open 'em with a Crucial Incision, when they are large, or when a _Cystis_ or Membranous Vehicle is to be extirpated. _How many sorts of Matter are there that issue forth in the Suppuration of Tumours?_ There are four sorts, _viz._ the _Pus_, _Ichor_, _Sanies_, and _Virus_. _What is_Pus_?_ It is a thick Matter, and white as Milk. _What is _Ichor_?_ It is a thick Matter like the _Pus_, but of divers Colours. _What is _Sanies_?_ It is a watery Matter that riseth up in Ulcers, almost after the same manner as the Sap in Trees. _What is _Virus_?_ {103} It is a kind of watry Matter, being whitish, yellowish, and greenish at the same time; which issueth out of Ulcers, very much stinking, and is endu'd with corrosive and malignant Qualities. _How many general Causes are there of Tumours?_ There are three, _viz._ the Primitive, the Antecedent, and the Conjunct: The Primitive is that which gives occasion to the Tumours; as for Example, a Fall or a Blow receiv'd. The Antecedent is that which supplies it with Matter, such is the Mass of Blood that thickens and maintains the _Phlegmon_. Lastly, the Conjunct Cause is the overflowing Blood or Matter, which immediately forms the Tumor. _What regard ought to be had to these three sorts of Causes in the Cure?_ The Primitive Cause may be prevented by avoiding the Falls, Blows, or other Hurts, and the Antecedent by diminishing the Plethory of the Blood, and cooling the whole Mass by Phlebotomy. The Conjunct Cause, which is the overflowing of the Blood, may be also remov'd in dispersing it by dissolving, or else in discharging it by Suppuration. _What is a _Crisis_?_ It is a sudden setling of Humours, which happens in Diseases, whereby they are usually terminated. _How are these Critical Setlings effected?_ By the Strength of Nature, which either expels the peccant Humours thro' the Belly, or carries them to the Habitude of the Body; for in the former she causeth Fluxes of Humours, Urine and Blood; as in the other she excites Sweatings, Tumours, and even a Gangrene it self. _In what Parts do the Critical Tumours usually arise?_ {104} In the Glandules, which the Ancients call'd the _Emunctories_ of the Brain, Heart, and Liver; for they gave the Name of Emunctories of the Brain to the thick Glandules which lie under the Ears, that of the Emunctories of the Heart to those that are under the Arm-Pits; and that of the Emunctories of the Liver to those under the Groin. Now Malignant Tumours may arise in all these parts, but the Venereal happen only in the Groin. * * * * * CHAP. III. _Of Natural Tumours._ * * * * * ARTICLE I. _Of the _Phlegmon_ and its Dependancies._ _What is a _Phlegmon_?_ It is a red Tumour occasion'd by the Blood diffus'd in some part, wherein it causeth extension, pain, and heat with beating. _Are_ Aneurisms _and_ Varices, _which are Tumours, made by the Blood, to be reckon'd among the_ Phlegmons? No, because the Blood that forms the _Aneurisms_ and _Varices_ is not extravasated nor accompany'd with Inflammation, but only a Tumour of Blood proceeding from the Dilatation of the Arteries and Veins. {105} _May _Echymoses_ or Contusions consisting of extravasated Blood, be esteem'd as _Phlegmons_?_ By no means, in regard that it is not sufficient that the Blood be extravasated for the producing of a _Phlegmon_; it must also cause Pain, Heat, and a Beating, with Inflammation, which is not to be found in the _Echymoses_, except in great ones, after they have been neglected for a long time; where the corrupted Blood ought to be let out immediately, to prevent the Inflammation, overmuch Suppuration, and many other ill Consequences. _Is the _Phlegmon_ always compos'd of pure Blood?_ No, it may happen sometimes to partake of Choler, Phlegm, or Melancholy; on which account it is nam'd an _Erysipelatous_, _Oedomatous_, or _Scirrhous Phlegmon_, always retaining the Name of the predominant Humour, which is the Blood; and so of the others. REMEDIES. _What are the Remedies proper for a _Phlegmon_?_ They are of two sorts, _viz._ General and Particular; the former having regard to the antecedent cause, and the other to the conjunct. The _Phlegmon_ is cur'd in its antecedent Cause, by Phlebotomy or letting Blood, by good Diet, and sometimes by Purgations, by which means the Plethory, Heat, and Alteration of the Blood is diminished; But Fomentations, Cataplasms and Plaisters facilitate the Cure in the conjunct cause, either by dissolving the Tumour, or bringing it to Suppuration. {106} _At what time is the Opening of a Vein necessary?_ In the Beginning and Increase. _What are the Remedies proper to be us'd immediately upon the first appearing of the Tumour?_ They are Resolvents and Anodynes; such as those that are prepar'd with Chervil boil'd in Whey, adding a little Saffron to wash the Tumour, and soak the Linnen Cloaths apply'd thereto, which are often renew'd, and may be laid on with the Chervil. Or else take the Urine of a healthful Person, wherein is boil'd an Ounce of Saffron for a Glass, and bath the Tumour with it. The Sperm of Frogs is also made use of to very good purpose, either alone, or with Lime-Water and Soap mixt together; or Oak-Leaves and Plantane beaten small, and apply'd. But Care must be more especially taken to avoid cooling Medicines, Oils, and Grease, which are pernicious in great Inflammations. _What ought to be done in the increase of the Tumour and Pain?_ They are to be asswag'd by mollifying and dissolving; to which end a Cataplasm or Pultis is to be made with the Leaves of Elder, Wall-wort or Dwarf-Elder, Mallows, Violet-Plants, Camomile, and Melilot; whereto is added beaten Line-seed; causing the whole Mass to be boil'd in Whey, and allowing to every Pint, or thereabout, a Yolk of an Egg, twenty Grains of Saffron, a quarter of a Pound of Honey, and the Crum of white Bread, till it comes to a necessary Consistence. Or else take Cow's Dung instead of the above-mention'd {107} Herbs, and mix with it all the other Ingredients, to make a Cataplasm, which must be renew'd at least every twelve Hours. _What is to be done in the State?_ If the Tumour cannot be dissolv'd (as was intended) it must be brought to Suppuration by Cataplasms, consisting of these Ingredients, _viz._ Garlick, White Lillies roasted under Embers, Milk, and _Unguentum Basilicon_. Or else only take a Glass of Milk, in which an Ounce of Soap is dissolv'd, to wet the Linnen apply'd to the Tumour; and let it be often reiterated: Otherwise make use of Sorrel boil'd with fresh Butter, and a little Leaven or Yeast. The Plaister _Diasulphuris_ is also most excellent either alone, or, if you please, mixt with _Diachylon_ and _Basilicon_. _What is to be done in the Declination after the Suppuration?_ The Ulcer must be at first gently dry'd with a Plaister of _Diasulphuris_ or _Diachylon_, and afterward that of _Diapalma_ may be us'd, and Ceruse or White Lead. _What Method is to be observ'd in case there be any Disposition toward a Gangrene?_ It is requisite during the great Inflammation to make use of good Vinegar, in an Ounce whereof is dissolv'd a Dram of White Vitriol, with as much _Sal Ammoniack_, to bath the Tumour: Or else take the Tincture of Myrrh and Aloes, with a little _Unguentum Ægyptiacum_, and afterward make a Digestive of Turpentine, the Yolk of an Egg, and Honey, mingling it with a little Spirit of Wine, or Brandy, if there remains any Putrifaction or Rottenness. {108} _Remedies for _Aneurisms_ and _Varices_._ _What is to be done in order to cure an _Aneurism_?_ When it is little, as that which happens after an Operation of Phlebotomy or letting Blood ill perform'd, it may be sufficient to lay upon the affected Part a thin Plate of Lead, or else a Piece of Money or Counter wrapt up in a Bolster, and to bind it on very streight: But a Piece of Paper chew'd is much better for that purpose. If the _Anuerism_ be considerable, an Astringent Plaister may be us'd, such as the following. Take _Bolus_, Dragon's Blood, Frankincence, Aloes, and _Hypocystis_, of each a Dram; mingle the whole with two beaten Eggs, and add Wax to give it the consistence of a Plaister, which may be apply'd alone, or mixt with an equal Portion of _Emplastrum contra Rupturam_, always making a small Bandage to keep it on. _Emplastrum de Cicuta_ hath also a wonderful effect. When the _Aneurism_ is excessive, it is absolutely necessary to proceed to a Manual Operation, the manner whereof shall be shewn hereafter in the Treatise of great Operations. _What is requisite to be done in the _Varices_?_ _Varices_ are not generally dangerous, but even conduce to the preservation of Health; nevertheless, if they become troublesome by reason of their greatness, and the Pains that accompanie 'em, they may be mollify'd with the following Remedy. Take the Mucilages of the Seeds of _Psyllium_ and Line, of each two Ounces; of _Populeon_ {109} two Ounces; _Oleum Lumbricorum_ & _Hyperici_, of each one Ounce; and of the Meal of Wheat one Ounce, adding Wax to make the Consistence of a Plaister; part of which spread upon Linnen or Leather, must be apply'd to the _Varix_, and ty'd thereto with a small Band. If the Blood abound too much, it may be discharg'd by the Application of Leeches, or by a Puncture made with a Lancet: Afterward lay upon the Part a Piece of Lead sow'd up in a Cloth, and let it be kept close with a proper Bandage. Otherwise you may make use of an Astringent, such as this. Take a Pomegranate, cut it in pieces, and boil it with as much Salt as may be taken up with the Tip of your Fingers, in a Gallon of strong Vinegar; then dip a Spunge in this Vinegar, apply it to the _Varix_, bind it on, and continue the use of it twice a Day for a Month together. _Remedies for _Echymoses_, Contusions, or Bruises._ _How are _Echymoses_ to be treated?_ All possible means must be us'd to dissolve 'em, by laying Slices of Beef upon the Part, renewing 'em very often, or applying Linnen Rags dipt in Spirit of Wine impregnated with Saffron. They may be also dissolv'd with the Roots of Briony grated and apply'd thereto, or else with Plaister or Mortar, Soot, Oil of Olives and _Unguentum Divinum_, a Mixture whereof being made, is to be put between two Rags, and laid upon the Tumour or Swelling. {110} If the _Echymosis_ happens in a Nervous Part, Balsam of _Peru_ may be us'd, or, for want thereof, _Oleum Lumbricorum_ & _Hyperici_, with luke-warm Wine, with which the Bolsters must be soak'd, to be laid upon it. When the _Echymosis_ is great, and much Blood is diffus'd between the Skin and the Flesh, the safest way is to make an Opening to let it out, lest a too plentiful and dangerous Suppuration should ensue, or even a Gangrene it self. However, a Surgeon ought to proceed in the curing of an _Echymosis_ in the Face with great Circumspection, which must be always prepar'd for Incision. _Of phlegmonous Tumors or Impostumes, and of Remedies proper for 'em._ _What are the Tumours or Impostumes that partake of a _Phlegmon_?_ They are the _Bubo_, Carbuncle, _Anthrax_, _Furunculus_, _Phyma_, _Phygeton_, _Panaritium_ or _Paronychia_, Burn, Gangrene, and Kibe or Chilblain. _What is a _Bubo_?_ A _Bubo_ is a Tumour which ariseth in the Groin, being accompany'd with Heat, Pain, Hardness, and sometimes a Feaver. _What is a Carbuncle?_ A Carbuncle is a hard Swelling, red, burning, and inseparable from a Fever: It is cover'd with a black Crust or Scab, that afterward falls off at the Suppuration, leaving a deep and dangerous Ulcer, and which sometimes doth not suppurate at all. {111} _What is an _Anthrax_?_ The _Anthrax_ is very near the same thing as the Carbuncle, only with this difference, that the latter always appears in the Glandulous Parts, and the _Anthrax_ every where else. _What is a _Furunculus_?_ It is a kind of Boil, or benign Carbuncle, which somewhat resembles the Head of a Nail, and is on that Account call'd _Clou_ by the _French_, causing Pains, as if a Nail were driven into the Flesh. _What is a _Phygeton_?_ The _Phygeton_ is a small, red, and inflam'd Exuberance, situated in the Miliary Glandules of the Skin, where it causeth a pricking Pain, without Suppuration. _What is a _Phyma_?_ The _Phyma_ appears after the same manner as the _Phygeton_, and suppurates. _What are the Remedies proper for all these sorts of phlegmonous Tumours and Impostumes?_ They are Cataplasms and Plaisters Anodyn, Emollient, Resolvent, and Suppurative, which are us'd proportionably as in the _Phlegmons_. _What is a _Gangrene_, _Sphacelus_, or _Esthiomenus_?_ The _Gangrene_ and _Sphacelus_ signifie the same thing, nevertheless are commonly distinguish'd; the former being a Mortification begun, and the _Sphacelus_ an entire or perfect Mortification; call'd also _Necrosis_ and _Sideratio_. An _Esthiomenus_ is a Disposition to Mortification, discover'd by the softness of the Part; and a Gangrene is defin'd to be a Mortification of a Part, occasion'd by the {112} Interception of the Spirits, and the Privation of the Natural Heat. _What are the causes of a Gangrene in general?_ Every thing that can hinder the Natural Heat from exerting it self in a Part; as strong Ligatures, astringent or resolvent Medicines, not conveniently us'd in great Inflammations; a violent Hæmorrhage; or Old Age, whereby the Spirits are exhausted; the bitings of Mad Dogs; excessive Cold, _&c._ _By what Signs is the Gangrene known?_ It is discover'd by the livid Colour of the Skin, which departs from the Flesh, the softness, coldness, and insensibility of the Part; and sometimes by its dryness and blackness, from whence exhales a cadaverous Stench, with _Sanies_ issuing forth after Punctures or Scarifications made therein. Lastly, a Gangrene is perceiv'd by the cold Sweats, Swoonings, _Syncope's_, and _Delirium's_ that invade the Patient, and which are all the Fore-runners of approaching Death. _Is a Gangrene only found in the Flesh, and soft Parts of the Body?_ It happens also in the Bones; and is then call'd _Caries_. _How is this _Caries_ or Gangrene of the Bone discover'd, when it lies hid under the Flesh?_ It is known by the black Colour of the Neighbouring Flesh, the Stink of the _Sanies_ that comes forth, the intolerable Pains felt thereabouts, which are fix'd and continual before the Impostume and Ulcer appear; but when the Ulcer is made, a kind of roughness may be perceiv'd in the Bone. {113} _REMEDIES._ _What are the Remedies proper for a Gangrene?_ They are those that take away the mortify'd and corrupt Parts, and recall the Natural Heat; both which Indications are exactly answer'd in the Extirpation of what is already corrupted, with the Incision-Knife; and the Restauration of the Natural Heat by the following Remedies. Take an Ounce of good Vinegar, steeping therein a Dram of White Vitriol, with as much _Sal Ammoniack_: Let it be us'd in bathing the Part; and apply thereto Bolsters well soak'd in the same Liquor. This Remedy is convenient in the first Disposition toward a Gangrene: Or, if you please, you may make use of the Yellow Water, which is made with Corrosive Sublimate and Lime-Water; taking, for Example, half a Dram of Corrosive Sublimate to be infus'd in a Pint of Lime-Water. But a Tincture of Myrrh and Aloes is more efficacious, wherein _Unguentum Ægyptiacum_ is steep'd; or else Lime-Water kept for that purpose, in which have been boil'd two Ounces of Sulphur or Brimstone, with two Drams of _Mercurius Dulcis_; adding four Ounces of Spirit of Wine, to make an excellent _Phegedænick_ Water, with which the Part may be bathed, and the Bolsters soak'd. If the Gangrene passeth to the Bone, the Ulcer must be immediately cleans'd with Brandy, and _Euphorbium_ afterward put into it, laying also some upon the Bolsters, and {114} abstaining from all sorts of Oils and Greases. But if these Remedies prove unprofitable, recourse is then to be had to the Incision-Knife, Fire, or Amputation; the manner of performing which several Operations, is explain'd hereafter. _What are Kibes or Chilblains?_ They are painful Tumours, which are often accompany'd with Inflammation; they happen more especially in the nervous and outward Parts, as the Heel, and are so much the more sensibly felt, as the Air and Cold are more sharp and Vehement. _What is to be done in order to cure these Kibes or Chilblains?_ The Heel or affected Part must be wash'd and dipt in Wine boil'd with Allum and Salt, whereof a Cataplasm may be afterward made, by adding Meal of Rye, Honey, and Brimstone. The Juice of a hot Turnep apply'd with _Unguentum Rosatum_, is also very good, or _Petroleum_ alone. _What is a _Panaritium_?_ _Panaritium_ or _Paronychia_, is a Tumour which generally ariseth in the Extremity of the Fingers, at the Root of the Nails: It is red, and accompany'd with very great Pain, even so exquisite, that the whole Arm is sensible thereof, insomuch that a Fever sometimes ensues, and a Gangrene; the Humour being contain'd between the Bone and the _Periosteum_, or that little Membrane with which it is immediately invested. _What Remedies are convenient for the curing of _Panaritium_?_ {115} Anodyn Cataplasms are to be first apply'd, that is to say, such as serve to asswage excessive Pain, as that which is compos'd of Millk, Line-seeds beaten, large Figs, the Yolk of an Egg, Saffron, Honey and _Oleum Lumbricorum_, with the Crum of white Bread. Afterward you may endeavour to dissolve it, by applying Oil of Almonds, _Saccharum Saturni_, and Ear-Wax, or else Balsam of Sulphur. The Plaister of Mucilages, and that of Sulphur or Brimstone, dissolv'd in Wine, is also a most excellent Resolvent and Anodyn. If it be requisite to bring this Tumour to Suppuration, white Lillies roasted under Embers may be added to the preceeding Cataplasm; or else a new Cataplasm may be made with Sorrel boil'd, fresh Butter, and a little Leaven. _What is a Burn_? A burn is an Impression of Fire made upon a Part, wherein remains a great deal of Heat, with Blisters full of serous Particles, or Scabs, accordingly as the Fire hath taken more or less effect. _What are the Remedies proper for a Burn_? A Burn is cur'd by the speedy Application of fresh Mud re-iterated many times successively; by that of peel'd Onions, _Unguentum Rosatum_, and _Populeon_, mixt with the Yolk of an Egg and unslack'd-Lime: Cray-Fishes or Crabs pounded alive in a Leaden-Mortar; and a great Number of other things. If the Burn be in the Face, you may more especially take the Mucilages of the Seeds of Quinces and _Psyllium_, and Frog's-Sperm, of {116} each an equal quantity, adding to every four Ounces twenty Grains of _Saccharum Saturni_. This Composition may be spread on the Part with a Feather, and cover'd with fine Brown Paper. It is an admirable and approved Receipt. If the Burn hath made an Escar or Crust, it may be remov'd with fresh Butter spread upon a Colewort or Cabbage Leaf, and apply'd hot. But in Case the Scab is too hard, and doth not fall off, it must be open'd, to give passage to the _Pus_ or corrupt Matter, the stay of which would occasion a deep Ulcer underneath. The same Method is to be observ'd in the Pustules or Blisters, two Days after they are rais'd, applying also the Ointment of quick Lime, Oil of Roses, and Yolks of Eggs. * * * * * ARTICLE II. _Of the _Erysipelas_ and its Dependances._ _What is an _Erysipelas_?_ An _Erysipelas_, commonly call'd _St. Anthony's Fire_, is a small Elevation produc'd by a Flux of Choler dispers'd and running between the Skin and the Flesh. It is known by its yellowish Colour, great Heat and Prickings. _REMEDIES._ _What are the Remedies proper for an _Erysipelas_?_ An _Erysipelas_ that ariseth in the Head and Breast is not without danger, and the Cure of {117} it ought to be undertaken with great Care in the Application as well of internal as external Remedies: For it is requisite to take inwardly a Dose of the Diaphoretick Mineral, Crabs-Eyes, Egg-shels, Powder of Vipers, and other Medicines; as also Potions that have the like Virtues, such as the following. Take four Ounces of Elder-Flower-Water, adding thereto a Scruple of the volatile Salt of Vipers or Hart's-Horn with an Ounce of Syrrup of red Poppies. Phlebotomy or Blood-letting hath no place here, unless there be a great Plethory, but frequent Clysters are not to be rejected, _viz._ such as are made of Whay, Chervil, Succory, and Violet-Plants, adding a Dram of Mineral Crystal dissolv'd with two Ounce of Honey of Violets. As for outward Applications, Linnen-Rags dipt in the Spirit of Wine impregnated with Camphire and Saffron, are to be laid upon the Tumour, and renew'd as fast as they are dry'd. An equal quantity of Chalk and Myrrh beaten to Powder, may also be strew'd upon a Sheet of Cap-Paper over-spread with Honey, and apply'd to the Part. If the Heat and Pain grow excessive, take half a Dram of _Saccharum Saturni_, twenty Grains of Camphire, as much _Opium_, with two Drams of red Myrrh, to be infus'd in a Gallon of White-Wine: Let this Liquor be kept to soak the Cloaths that are laid upon the _Erysipelas_, and often renew'd. But to dress the Face, a Canvass Cloth may be us'd, which hath been dipt in a Medicine prepar'd with a {118} Gallon of Whey, two Yolks of Eggs, and a Dram of Saffron. Moreover amidst all these Remedies, it is necessary to oblige the Patient to keep to a good Diet, and to prescribe for his ordinary Drink a Diet-Drink made of Hart's-Horn, the Tops of the lesser Centory, Pippins cut in Slices with their Skins, and Liquorish; a little good Wine may be also allow'd, with the Advice of the Physician. _Of _Erysipelatous_ Tumours or Impostumes, and their Remedies._ _What are the Tumours or Impostumes that partake of the Nature of an _Erysipelas_?_ They are the dry and moist _Herpes_, the former being that which is call'd the Tetter or Ring-Worm; and the other a kind of yellow-Bladders, Pustules, or Wheals, that cause itching, and raise small corroding Ulcers in the Skin: To these may be added divers sorts of Scabs and Itch. The Remedies prescrib'd for the _Erysipelas_ may be us'd for both these kinds of _Herpes_; as also Lotions or Bathing-Liquors made of Lime-Water, and a Decoction of Wormwood and _Sal Ammoniack_, allowing half a Dram to four Ounces of Liquor. Or else take half a Dram of _Sal Saturni_, and put it into a Glass of the Decoction of Fumitory or Chervil. You may also make use of the Oil of Tartar _per deliquium_, to make a Liniment either alone, or mingl'd with the above-mention'd Decoctions. * * * * * {119} ARTICLE III. _Of the _Oedema_._ _What is the _Oedema_?_ It is a white soft Tumour, with very little sense of Pain, which ariseth from the Settling of a pituitous Humour. _What are the Remedies proper for an _Oedema_?_ They are Fomentations, Cataplasms, Liniments, and Plaisters. The Fomentations are made with Bundles of Wall-Wort or Dwarf-Elder, thrown into a hot Oven after the Bread is bak'd, and sprinkled with Wine: Afterward being taken out smoaking, they are unty'd, open'd, and wrapt about the Part, putting a warm Linnen Cloth over 'em. This Operation is to be re-iterated; and by this means the Humour is dissolv'd thro' Transpiration by Sweat. The Cataplasms are compos'd of Camomile, Melilot, St. _John_'s-Wort, Sage, Wall-Wort, Pellitory of the Wall, Roots of Briony and Onions, all boil'd together in White Wine with Honey, adding, if you please, a few Cummin or Fennel Seeds beaten. Cataplasms are also made of Horse-Dung and the Seeds of Cummin beaten, which are boil'd in strong Vinegar, and mixt with Barly-Meal to the Consistence of Pap. The Plaisters are prepar'd with an Ounce of _Diapalma_, half on Ounce of _Martiatum_, a Pint of Oil of Lillies, half an Ounce of {120} Cummin-Seeds powder'd, half a Dram of _Sal Ammoniack_, and an Ounce of yellow Wax to make a Consistence. If any hardness remains, the Plaister of Mucilages may be apply'd, or that which is made of the Gums _Bdellium_, _Ammoniack_, and _Galbanum_, dissolv'd in Vinegar. But Care must be taken not to omit the Purgatives of Jalap to the quantity of a Dram in a Glass of White-Wine; or of half an Ounce of Lozenges of _Diacarthamum_, which are effectual in drawing out the bottom of pituitous and serous Humours that nourish the _Oedema's_. _Of _Oedomatous_ Tumours and Impostumes._ _What are the kinds of Tumours that partake of the Nature of an _Oedema_?_ They are the _Phlyctæna_, the _Emphysema_, the _Batrachos_ or _Ranunculus_, the Wen, the _Talpa_, the _Bronchocele_, the _Ganglion_, the _Fungus_, the Scurf, the _Scrophula_ or King's-Evil, and all sorts of Dropsies both general and particular. _What are _Phlyctæna's_?_ They are Pustules or Blisters fill'd with a white and somewhat yellowish Humour. _What is an _Emphysema_?_ It is a kind of flatuous Tumour, wherein Wind is contain'd, with a little slimy Phlegm. _What is a _Batrachos_ or _Ranunculus_?_ It is a Blister fill'd with slimy Water, that ariseth under the Tongue near the String, and in _French_ is call'd _Grenouillette_, or _the little Frog_; which is the same with its _Greek_ and _Latin_ Names. {121} _What is a Wen?_ It is a Tumour consisting of thick plaistry Phlegm, which is reckon'd among the _Encysted_. _What is a _Talpa_?_ It is a soft and very broad Tumour, which usually appears in the Head and Face, containing a white, thick and pituitous Matter. _What is a _Bronchocele_?_ It is a bunch'd Tumour which ariseth in the Throat, and causeth it to swell extremely; being compos'd of thick Phlegm mix'd with a little Blood, and ranked among the _Encysted_ Tumours. _What is a _Ganglion_?_ It is a very hard Tumour, void of Pain and wavering, produc'd by thick Phlegm: But it is always found upon some Nerve or Tendon. _What is a _Fungus_?_ It is a spungy Tumour that grows upon Tendons bruis'd or weaken'd by some Hurt. _What is the Scurf?_ It is a whitish and scaly Tumour rais'd in the Skin of the Head by a viscous and mixt Phlegm, having its Root in the bottom of the Skin. _What is the _Scrophula_ or King's-Evil?_ _Scrophulæ_ or _Strumæ_, commonly call'd _the King's-Evil_, are Tumours that generally shew themselves in the Glandules of the Neck, and in all those Parts where there are any. They consist of a viscous, serous, and malignant Phlegm, The Source or Root whereof is suppos'd to be in the Glandules of the Mesentery. They are also of the number of the _Encysted_ Tumours. {122} _What is the Dropsie?_ It is a soft Tumour occasion'd by the setling of abundance of serous Matter in the Parts where it appears. _How many sorts of Dropsies are there?_ There are three general _Species_, _viz._ the _Ascites_, _Tympanites_, and _Leucophlegmatia_. _What is an Ascites?_ It is a kind of Dropsy that forms the Tumour or Swelling of the _Abdomen_ or lower Belly, by a Mass of Water. _What is a _Tympanites_?_ It is a kind of Dropsy, which in like manner causeth a Tumour or Swelling in the lower Belly, with this difference, that a great deal of Wind is mixt with the Water, which renders the Tumour transparent, and sounding, as it were a Drum; whence this Disease hath taken its Name. _What is the Dropsy call'd _Leucophlegmatia_?_ It is a Tumour, or, to speak more properly; a general Swelling or Bloating of all the other Parts of the Body, as well as of the lower Belly. It is produc'd by a viscous and mucilaginous sort of Phlegm; whence it happens that the Print of the Fingers remains in those places that have been press'd. _What are the particular kinds of Dropsies?_ They are those that are incident to different Parts, of which they bear the Names; as the _Hydrocephalus_, which is the Dropsy of the Head; the _Exomphalus_, of the Navel, and the _Hydrocele_ of the _Scrotum_. There is also a Dropsy of the Breast, and that of the _Matrix_. {123} _What are the Remedies proper for all these sorts of Tumours or Dropsies?_ They are in general all those that are agreeable to the _Oedema_, which are variously us'd, as Liniments, Fomentations, Cataplasms, and Plaisters: Internal Medicines ought also to be much consider'd, as Diaphoreticks, Sudorificks, and Purgatives, when they are assisted by a regular Diet. A Decoction of the Roots of Briony with Cinnamon and Liquorish, provokes Urine very much; as well as a Decoction of Turneps and Carrets, and an Infusion of Sage in White-Wine. * * * * * ARTICLE IV. _Of a _Scirrhus_, and its peculiar Remedies._ _What is a _Scirrhus_?_ It is a hard unmoveable Tumour, almost altogether void of Pain, and of a livid dark Colour; which is form'd of a Melancholick Humour, frequently succeeding _Phlegmons_ and _Oedema's_ that have not been well dress'd with convenient Remedies. _How is a _Scirrhus_ cur'd?_ By mollifying or dissolving it, and seldom by bringing it to Suppuration. It may be mollify'd by the application of a Cataplasm or Pultis, compos'd of the Leaves of Violet-Plants, Mallows, Beets, Elder, Rue, and Wormwood, with Camomile-Flowers, {124} Horse-Dung, Cow-Dung, and White Lillies. The whole Mass is to be boil'd together in Wine, afterward adding Honey and Hogs-Lard, to make a Cataplasm thereof with the Crum of White Bread. It is dissolv'd with Plaisters compos'd of those of _Diachylon_, Melilot, and Mucilages, to which is added _Oleum Lumbricorum_, and Flower of Brimstone. To render the Remedy more effectual, Oil of Tobacco may be also mixt with it, and Gum _Ammoniack_ dissolv'd in Vinegar. Furthermore, these Topical or outward Medicines are to be accompany'd with others taken inwardly, which serve to prepare the Humours for convenient Evacuations; Such are Crab's-Eyes, the Decoctions of _Sarsaparilla_, the use of good Wine, and light Meats of easie Digestion. _Of _Scirrhous_ Tumours, and their Remedies._ _What are the Tumours that partake of the Nature of a _Scirrhus_?_ They are the _Polypus_, _Carcinoma_, _Sarcoma_, _Natta_, and _Cancer_. _What is a _Polypus_?_ It is an Excrescence of fungous Flesh arising in the Nostrils: But _Hippocrates_ confounds the _Carcinoma_ and _Sarcoma_ with the _Polypus_, of which he says they are only a _Species_. _What is the _Natta_?_ It is a Tumour or Excrescence of Flesh that appears in the Buttocks, Shoulders, Thighs, Face, and every where else, the various Figures {125} of which cause it to be call'd by different Names. For one while it resembleth a Gooseberry, at another time a Mulberry, and at another time a Melon or Cherry. Sometimes also these Swellings are like Trees, Fishes, Birds, or other sorts of Animals, according to the ardent desire that Women with Child have had for things that they cou'd not obtain when they longed for 'em. _What are the Remedies proper for the _Polypus_, and other kinds of Excrescences of the like Nature?_ The _Polypus_ may be cur'd in the beginning, but it is to be fear'd lest it degenerate into an incurable Cancer, when it hath been neglected or ill dress'd. Besides the general Remedies, which are letting Blood a little, and reiterated Purgations, with an exact Regulation of Diet, there are also particular Medicaments which dry up and insensibly consume the Excrescence; as a Decoction of Bistort, Plantain, and Pomegranate-Rinds in Claret-Wine, which is to be snuff'd up the Nose many times in a Day, and serves to soak the small Tents that are put up therein, as also often to cool the Part, adding a little Allum and Honey. The Patient must sometimes likewise keep in his Mouth a Sage-Leaf, sometimes a piece of the Root of Pellitory of _Spain_; and at another time Tobacco or some other thing of this Nature, which causeth Salivation. If the Tumour continues too long, and doth not yield to the above-mention'd Remedies, it is necessary to proceed to a Manual Operation, {126} which is very often perform'd with good Success. As for the _Natta's_, it is most expedient not to meddle with 'em at all; nevertheless these Marks which Infants bring along with 'em into the World, are frequently defac'd by an Application of the After-Burdens, whilst they are as yet warm, as soon as their Mothers are deliver'd. _What is a Cancer?_ It is a hard, painful, and ulcerous Tumour, produc'd by an adult Humour, the Malignity whereof can scarce be suppress'd by any Remedies. _How many sorts of Cancers are there?_ There are two kinds, _viz._ The Primitive and the Degenerate; the Primitive Cancer is that which comes of it self, and appears at first about the bigness of a Pea or Bean, which nevertheless doth not cease to cause an inward Pain, continual, and pricking by intervals; during this time it is call'd an Occult Cancer; but when grown bigger, and open'd, it bears the Name of an Ulcerated Cancer; which is so much the less capable of being cur'd or asswag'd, as it makes it self more conspicuous by its dreadful Symptoms, or concomitant Circumstances. The Degenerate Cancer is that which succeeds an obstinate and ill-dress'd Tumour or Impostume, and which becomes an Ulcerated Cancer, without assuming the Nature of a blind or occult one. _What Remedies are requisite to be apply'd to a blind Cancer?_ {127} In regard that it cannot be known in this Condition without difficulty, it is often neglected; nevertheless it is a Matter of great Moment to prevent its Consequences, more especially by a good Diet, and by general Remedies, which may gently rectifie the intemperature of the Bowels: Afterwards Baths may be prescrib'd, together with the use of Whey Asses-Milk, and Specificks in general, as Powders of Crab's Eyes, Vipers, Adders, and others. As for Topical Remedies, none are to be administer'd, except it be judg'd convenient to apply to the Tumour a Piece of Lead rubb'd with Quick-silver; all others serving only to make the Skin tender, and apt to break. The Patient may also take for his Drink Water of _Scorzonera_ and Hart's-Horn, with the Flowers of Bugloss or Borage, and Liquorice: Or else Quick-silver-Water alone, boiling an Ounce of it in a Quart of Water every time, the Quick-silver always remaining at the bottom of the Vessel. _What are the Remedies for an ulcerated Cancer?_ Besides the general ones, that are the same with those of the blind Cancer, there are also Topical, which may take place here. The Powders of Toads, Moles, Frogs, and Crabs calcin'd, cleanse the Ulcers perfectly well. A Decoction of Vipers and Crabs may serve to bath 'em, and some of it may be taken inwardly. Detersives made of Lime-Water, or Whey clarify'd, and boil'd with Chervil are very good; and (if you please) you may add Camphire or _Saccharum Saturni_. {128} If the Pains grow violent, recourse is to be had to _Laudanum_, one or two Grains whereof may be given in a little Conserve of Roses. When the Cancer is situated in the Glandules or Flesh, the Extirpation of it may also be undertaken with good Success. As for the manner of handling Degenerate Cancers, respect must be always had to the kind of Tumour, from whence it deriv'd its Original. * * * * * CHAP. IV. _Of Bastard or _Encysted_ Tumours._ _What is an _Encysted_ or Bastard Tumour or Impostume?_ It is that which is made of a Setling of mixt and corrupt Humours, the Matter whereof is contain'd in certain proper _Cystes_ or Membranous Bags. _What are the kinds of these Tumours?_ They are the _Steatoma_, the _Atheroma_, the _Meliceris_, the Wen, the _Bronchocele_, and the _Scrophula_ or King's-Evil. _How is the difference between these Tumours discern'd?_ The _Steatoma_ is known by its Matter resembling Suet; as that of the _Atheroma_ resembleth Pap; and that of the _Meliceris_ is like Honey: These three Tumours cannot be well distinguish'd on the outside, in regard that they do not change the natural Colour of the Skin, which {129} equally retains in all three the print of the Fingers that press it. But the _Bronchocele_ is discover'd by the Place and Part which it possesseth; that is to say, the Throat; as also by its somewhat hard consistence without the Alteration of the Skin. The _Scrophulæ_ or King's-Evil Swellings are known by their unequal Hardness, and their situation in the Glandules, either in the Neck, Arm-pits or elsewhere, without alteration likewise of the Skin. _REMEDIES._ _Want is the Method to be observ'd in curing these sorts of Tumours?_ An Attempt is to be made to dissolve 'em, as in all the others; nevertheless the safest way is to bring 'em to Suppuration, and to extirpate the _Cystes_, which are apt to be fill'd again after the Dissipation of the Humour. _What are the Medicines proper to dissolve these Tumours?_ They are all such as may be us'd for the _Oedema_ and _Scirrhus_; but the Specificks or particular Remedies are these: Take Rosemary, Sage, Wormwood, Elder, great Celandine, Camomile, Melilot, St. _John_'s-Wort, and Tobacco; boil 'em in White-Wine with Soot and Mercurial Honey, adding, thereto Cummin-seeds beaten, and _Oleum Lumbricorum_, to make a Cataplasm, which is to be renew'd twice a Day. Afterward if the Tumour be not dispers'd, you may apply the following Plaister, which hath an admirable Effect. {130} Take an equal Portion of the Plaister of _Diachylon_, _Devigo_, and four times as much _Mercury_, and _Emplastrum Divinum_; let 'em be dissolv'd together; then intermix Saffron, and Oil of Tobacco, to make a Plaister with the whole Mass, which may be spread upon thin Leather, and apply'd to the Tumour, without taking it off only once every eighth Day, to cool it; so that it must be laid on again after having wash'd and bath'd the Part with warm Urine or Brine. But it is to be always remember'd that external Remedies take effect only imperfectly, unless they are assisted by internal, such as in this case are reiterated Purgations, join'd with a regular Diet. _What are the Remedies proper to excite Suppuration?_ To this purpose those may be us'd that serve in other kinds of Tumours: But as for the extirpation of the _Cystis_, it is done by dividing the Tumour into four Parts, by procuring Suppuration, and by consuming the Bag by little and little. The _Bronchocele_ alone will not admit this Extirpation, by reason of the great Number of Nerves, Veins, and neighbouring Arteries amidst which the Tumour is settl'd. However _Bronchotomy_, or opening the Throat, may be perform'd; which is an Operation peculiar to this Tumour. * * * * * {131} CHAP. V. _Of Critical, Malignant, Pestilential, and Venereal Tumours and Impostumes._ _What difference is there between Critical, Malignant, Pestilential, and Venereal Tumours?_ It consists in these particular circumstances, _viz._ that Critical Tumours or Impostumes are indifferently all such as are form'd at the End or Termination of Diseases, in whatsoever Place or Part they appear. Malignant Impostumes or Tumours are those that are obstinate, and do not easily yield to the most efficacious Remedies. Pestilential Impostumes or Tumours are those that are accompany'd with a Fever, Swooning, Head-ach, and Faintness: They usually arise in the time of a Plague or Pestilence, and are contagious. Venereal Tumours or Impostumes are those that appear only at the bottom of the Groin, and are the product of an impure _Coitus_. However, the Critical Impostume may be Malignant, Pestilential, and Venereal; the Malignant Impostume may be neither Critical, nor Pestilential, nor Venereal: But the Pestilential and Venereal Tumours are always Malignant. {132} _What are the ordinary kinds of Critical Tumours or Impostumes?_ They are the _Anthrax_, the Boil, the _Phlegmon_, and the _Parotides_ or Swellings in the Almonds of the Ears. _What are the kinds of Malignant Tumours or Impostumes?_ They are the _Cancer_, the _Scrophula_ or King's-Evil; and others of the like Nature. _What are the kinds of Pestilential Tumours or Impostumes?_ They are Carbuncles that break out every where; a sort of _Anthrax_ which appears under the Arm-pits, and Bubo's in the Groin. _What are the kinds of Venereal Tumours or Impostumes?_ They are Botches or Bubo's and Cancers that arise in the Yard; as also Wens and _Condyloma's_ in the Fundament. _What is the difference between a Pestilential and a Venereal Buboe?_ They may be distinguish'd by their Situation, and respective Accidents; the Pestilential lying higher, and the Venereal lower: Besides, a Fever, Sickness at the Heart, and an universal Faintness or Weakness, are the ordinary concomitant Circumstances of the former; whereas the Venereal Buboe is always the consequence of an impure _Coitus_, and is attended with no other Symptoms than those of common Tumours, _viz._ Pain, Heat, Shootings or Prickings, &c. As for the Remedies, they may be sought for among those that have been already prescrib'd for Tumours. * * * * * {133} CHAP. VI. _Of the Scurvy._ This Disease is known by the Ulcers of the Mouth, which are very stinking; as also by excessive Salivation, great Pains in the Head, Dizziness, frequent Epilepsies, Apoplexies, and Palsies. The Face, being of a pale red, and dark Colour, is sometimes puff'd up or bloated, inflam'd, and beset with Pustules: The Teeth are loose and ake, the Gums are swell'd, itch, putrifie, exulcerate, and are eaten with the Canker; and the Jaw is almost unmoveable: The Members are bow'd, and cannot be extended: The Patients become stupid and drowsie, so that they fetch their Breath with difficulty, are obnoxious to Palpitations of the Heart and Coughs, and fall into Swoons: The Ulcers sometimes are so malignant, that their Cheeks are entirely eaten up, and their Teeth seen: They are also much inclin'd to Vomitting, Looseness, and Gripes; and their Entrails are swell'd: They have red and livid Pustules on their Belly and Privy-parts, which sometimes break out into Ulcers; their whole Body being dry'd, _&c._ This Disease may be easily cur'd in the beginning; but when it is grown inveterate, and invades the Bowels, it becomes incurable; as well as when it is the Epidemical Disease of {134} the Country, or the Persons afflicted with it, are old, or well advanc'd in Years. In undertaking the Cure, it is requisite to begin with a good Diet, and to sweeten the Blood, let the Patient take the Broth of boil'd Fowl; eating Pullets and Eggs; in the Broth may also be put divers sorts of Antiscorbutick Herbs; _viz._ Cresses, Spinage, Parsly-Roots, Sparagus, Smallage, _Scorzonera_, Scurvy-Grass, _&c._ Let him eat nothing that is high season'd, nor acid or sharp; let him drink pure Claret, without any adulterate Mixture; let him use moderate Exercise and Rest; Lastly, let him keep his Mind sedate, and free from all manner of violent Passion. The following Remedies taken inwardly are very good for the Scurvy, _viz._ the Tincture of Flints from ten Grains to thirty; Diaphoretick Antimony, from six Grains to thirty; sweet Sublimate, from six Grains to thirty; _Mars Diaphoreteus_, from ten Grains to twenty; _Crocus Martis Aperitivus_, from ten Grains to two Scruples; prepar'd Coral, from ten Grains to one Dram; Volatile Spirit of _Sal Ammoniack_, from six Drops to twenty; Water of Cresses, from fifteen Drops to one Dram; Spirit of Scurvy-grass, from ten Drops to one Dram; Tincture of Antimony, from four Drops to twenty; Oily Volatile _Sal Ammoniack_, from four Grains to fifteen; Spirit of _Guyacum_, from half a Dram to a Dram and a half; Vitrioliz'd _Tartar_, from ten Grains to thirty; the Volatile Salt of _Tartar_, Urine, Vipers, and Hart's-Horn, of each from six Grains to fifteen; the Spirit of Gum _Ammoniack_, from eight Drops to sixteen; White {135} _Mercury_ Precipitate, from four to ten Grains; _Mercurial Panacæa_, from six Grains to two Scruples. We shall shew the manner of compounding 'em in our Treatise of Venereal Diseases. It is also expedient to give Emollient and Detersive Clysters to the Patient at Night going to bed, his Body being always kept open with convenient Diet-drinks: Afterward let him take gentle Sudorificks, such as are made of the Decoctions of Fumitory, wild Cicory, Dandelion, Hart's-Tongue, Scabious, the lesser House-Leek, Germander, Borage, _Scorzonera_-Root, and Polypody, with Flowers of Broom, Elder, and Marygold. These are stronger for cold Constitutions, _viz._ Decoctions of Scurvy-Grass, _Lepidium_, Arse-smart, the lesser Celandine, Wormwood, little House-Leek, _Trifolium Febrinum_, Angelico, Juniper-Berries, _&c._ Convenient Decoctions to wash the Mouth may be made with Sage, Rosemary, Hyssop, Oak-Leaves, Scurvy-Grass, Cresses, Tobacco, Roots of Bistort, _Aristolochy_ or Birth-Wort, Tormentil, Flower-de-Luce, _Balaustia_ or Pomegranate-Flowers, Red Roses, _&c._ To corroborate the Gums, Gargarisms are made of Anti-Scorbutick Plants; as of Spirit of Scurvy-Grass two Drams, one Scruple of Spirit of Vitriol, one Scruple of common Salt, four Ounces of Rose-Water and Plantane-Water. But if the Gums are putrefy'd, they are to be rubb'd with Honey of Roses, and some Drops of Spirit of Salt. To asswage the Pains of the Members, Bathings and Fomentations are to be us'd; and a {136} Decoction of Saxifrage taken inwardly, with some Grains of _Laudanum_ is good for that Purpose. To allay the Gripes, Clysters may be given with Whey, Sugar, Yolks of Eggs, Syrrop of Poppies, and Oils of Earth-Worms, Scurvy-Grass, Camomile, _&c._ Against the Scorbutick Dropsy, take the Essence of _Trifolium Febrinum_ and Elicampane, from twenty four Drops to thirty, and continue the use thereof. Milk taken inwardly hinders Vomitting; and a Broth or Gelly of Crabs sweetens the Blood. The Looseness may be stopt with the Essence of Wormwood, and Spirit of _Mastick_; as also the Fever with Febrifuges and Anti-scorbuticks. The Spots may be fomented with Decoctions of Aromatick and Anti-Scorbutick Herbs and Nitre. For the Ulcers of the Legs, pulverize an equal quantity of _Saccharum Saturni_, _Crocus Martis_, Myrrh, and _Mercurius Dulcis_, and lay it upon the Bolsters that are to be apply'd to the Sores. To mollifie the sharpness of Acid Humours, this is a good Remedy: Prepare half an Ounce of Spirit of Scurvy-Grass, two Drams of tartariz'd Spirit _Ammoniack_, a Dram of the Tincture of Worms. Take thrice a Day fifteen or twenty Drops of this Liquor, in a Decoction of the Tops of Firr. Against the Tubercles, take two Handfuls of the Flowers of Camomile and Elder, three Drams of Briony-Root, and an Handful of White-Bread Crum; Boil the whole Composition in Milk, and make Cataplasms thereof. {137} To mitigate the Pains in the Head, take twenty or thirty five Drops of the Tincture of Amber, in Anti-scorbutick Spirits or Waters. The difficulty of Respiration may be remov'd by a Medicinal Composition made of two Drams of an Anti-scorbutick Water, two Drams of the Essence of Elicampane, and half a Dram of the Spirit of Gum _Ammoniack_; take three or four Spoonfuls thereof several times in a Day. To prevent the putrefaction of the Gums, take one Dram of the Tincture of Gum _Lacca_, three Drams of the Spirit of Scurvy-Grass, with fifteen or twenty Drops of Oil of Tartar made _per Deliquium_, and rub the Gums with this Composition many times in a Day. Brandy in which Camphire is infus'd, or Spirit of Wine, is likewise a most excellent Remedy; as also all Lotions or Washes made with the Waters or Decoctions of Anti-scorbutick Plants. For Leanness, Goat's-Milk with the Spirit of Scurvy-Grass may be us'd, and other Waters drawn from Anti-scorbutick Plants. The Apozemes or Decoctions of Endive, Cicory, Sorrel, _Becabunga_, and Snail-Water, are in like manner very good for the same purpose. Ointment of _Styrax_ is frequently us'd in the Hospital call'd _Hôtel-Dieu_ at _Paris_, and apply'd to Spots and callous Swellings that arise in the Legs. * * * * * {138} A TREATISE OF _Wounds, Ulcers, and Sutures_. * * * * * CHAP. I. _Of Sutures._ Sutures or Stitches are made only in recent, and as yet bleeding Wounds, when they cannot be re-united by Bandage, as are the transverse; provided there be no Contusion, nor loss of Substance, nor great Hæmorrhages, as also that the Wounds were not made by the biting of venomous Beasts, that there be no violent Inflammations, and that the Bones are not laid open; because generally 'tis necessary to cause 'em to be exfoliated; neither is this Operation to be perform'd in the Breast, by reason of its Motion. The Instruments proper for the making of Stitches, are streight and crooked Needles, {139} with waxed Thread; and these Sutures are of four sorts, _viz._ first the _Intermittent Stitch_ for transverse Wounds; the second for the Hare-Lip; the third, commonly call'd the _Dry Stitch_, for superficial Wounds; and the fourth, term'd the _Glover's Stitch_. The Intermittent Stitch is that which is made at certain separated Points, according to the following manner: After having taken away all extraneous Bodies out of the Wound, let a Servant draw together its Sides or Lips; and let a Needle with waxed Thread be pass'd thro' the middle from the outside to the inside, several Points being made proportionably to its length. It is requisite to pierce a good way beyond the Edge of the Wound, and to penetrate to the bottom, lest any Blood shou'd remain in the Space, that might hinder the reuniting. If the Wound hath Corners, the Surgeon begins to sow there; and before the Knot is made, causeth the Lips of the Wound to be drawn exactly close one to another: The Knots must be begun with that in the middle, and a single one is first made on the side opposite to the running of the Matter; laying upon this Knot (if it be thought convenient) a small Bolster of waxed Linnen, on which is tied a Slip-Knot, to the end that it may be untied if any bad Accident should happen. If a Plaister be apply'd to the Wound after the Stitching, a small Bolster is to be laid over the Knots, to prevent their sticking to the Plaister. In case any Inflammation happens in the Wound, the Knots may be loosen'd and ty'd again when the Symptoms cease: But {140} if the Inflammation continue, the Threads are to be cut by passing a Probe underneath: When the Wound is clos'd, the Threads are cut in like manner with a Probe; and in drawing 'em out, a Finger must be laid near the Knot, lest the Wound should open again. To make the second sort of Stitch for the Hare-Lip, a small streight Needle is pass'd into the sides of the Wound, and the Thread is twisted round the Needle, by crossing it above at every Stitch. To form the _Dry Stitch_ in very superficial Wounds, a piece of new Linnen-Cloth is to be taken, wherein are made Digitations, or many Corners; the Selvedge or Hem ought to be on the side of these Corners or Digitations; and a small Thread-Lace is ty'd to every one of 'em. Afterward this Cloth is dipt in strong Glue, and apply'd about a Finger's breadth from the Edges of the Wound; so that a piece thereof being stuck on each side, the Laces may be ty'd together, to cause the Lips of the Wound to meet. To make the _Glover's Stitch_, the Operator having drawn together the Lips of the Wound, holds 'em between two Fingers, passeth a Needle underneath 'em, and soweth 'em upward all along, after the manner of _Glovers_. * * * * * {141} CHAP II. _Of Wounds in general._ _What is a Wound?_ A Wound is a recent, violent, and bloody Rupture or Solution of the Natural Union of the soft Parts, made by a pricking, cutting, or bruising Instrument. _What ought to be observ'd before all things in the curing of Wounds?_ It is requisite to take notice of their differences, as well as of the Instruments with which they were made; to the end that Consequences may be drawn from thence for the Application of proper Remedies. _From whence arise the differences of Wounds, and which be they?_ They are taken either from their Figure or Situation: With regard to their Figure, they are call'd Long, Broad or Wide, Triangular Great, Little, Superficial, or Deep; and with respect to their Situation, they are term'd Simple, Complicated, Dangerous, or Mortal. _What is a Simple and a Complicated Wound?_ A Simple Wound is that which only opens the Flesh, and hath no other concomitant Circumstances; but a Complicated Wound, on the contrary, is that which is attended with grievous Symptoms, as Hæmorrhages, Fractures of Bones, Dislocation, Lameness, and others of the like Nature. {142} _What is a dangerous and mortal Wound?_ A dangerous Wound is that which is complicated the Accidents whereof are dreadful: As when an Artery is open'd or prick'd, when a Nerve or Tendon is cut, or when the Wound is near a Joynt and accompanied with a Dislocation or Fracture. A mortal Wound is that which must be inevitably follow'd by Death; as is that which is situated deep in a principal Part necessary for the Preservation of Life. _What are the Parts wherein Wounds are mortal?_ They are the Brain, the Heart, the Lungs, the _Oesophagus_ or Gullet, the Diaphragm, the Liver, the Stomach, the Spleen, the small Guts, the Bladder, the Womb, and generally all the great Vessels. _Wherein doth the Cure of Wounds consist?_ In helping Nature readily to procure the reuniting of the Parts that have been divided, after having taken away or asswag'd every thing that might cause an Obstacle. _What are the things that hinder the speedy reunion of the Parts?_ They are extraneous Bodies found therein, as Bullets, Flocks, and Pieces of Wood or Stone, &c. As also sometimes the Accidents which attend 'em; as an _Hæmorrhage_ or Flux of Blood, Inflammation, _Esthiomenus_ or Mortification, _Hypersarcosis_, or an Excrescence of Flesh, Dislocation, the Fracture of a Bone, the Splinter of a Bone, & sometimes a contrary Air. {143} _REMEDIES._ _What are the Remedies proper for stopping an _Hæmorrhage_ or Flux of Blood?_ The common Remedy is a kind of Cataplasm, made up with the Powders of Aloes, Dragons-Blood, Bole Armenick and Whites of Eggs, which are mix'd together and laid upon the Wound. But the following is an excellent one. Take two Ounces of Vinegar, a Dram of _Colcothar_, two Drams of _Crocus Martis Astringens_; beat the whole together, steeping _Muscus Quercinus_ therein; then throw upon it the Powder of Mushrooms, or of _Crepitus Lupi_: Apply this Remedy, and you'll soon stop the _Hæmorrhage_, taking Care nevertheless to bind the Part well, otherwise the Astringents do not readily take Effect. To this Purpose you may also make use of Cobwebs, Mill-Dust, and the Powder of Worm-eaten Oak; or else take Oven-Soot mixt with the Juice of the Dung of an Ass or Ox, adding only thereto the White of an Egg. Besides these Remedies there are also actual and potential Cauteries, or simple Ligatures, which are infallible. Indeed the actual Cautery is not always sure; because when the Escar made by the Fire, falls off the Hæmorrhage breaks out again as before: but the potential Cautery is almost always successful; such as the following. Take about an equal Quantity of Vitriol and Powder of Mushrooms; apply 'em upon a little Lint to the Place where the Blood issueth {144} forth, and you'll see it stop immediately: But Care must be taken to avoid touching a Nerve or Tendon; by reason that the Vitriol is apt to excite Convulsions. _How is the Inflammation and Mortification of a Wound Suppress'd?_ If the Inflammation proceeds from the Presence of an Extraneous Body, it must be taken away as soon as possible with a Pair of Forceps, and if from the Quantity of _Pus_ or corrupt Matter, it must be let out. But in case the Inflammation ariseth from extreme Pains, they are to be asswaged with Cataplasms or Pultises and anodyn Liniments, such as those that have been already prescribed in the Cure of the _Phlegmon_: or else the Part may be bath'd with Camphirated Spirit of Wine, mixt with as much Water: _Saccharum Saturni_ infus'd in Lime-water, performs the same Effect, and the Water of Crabs alone is admirable in its Operation. Against the _Esthiomenus_ or Mortification, make use of Wine boil'd with Wormwood, St. _John_'s Wort, Rosemary and Aloes; or else take the Tincture of Aloes and Myrrh, or Spirit of Wine alone impregnated with Camphire and Saffron. _What is to be done in Case a Convulsion happens by reason of a wounded Nerve or Tendon?_ If the Convulsion be caus'd by the Presence of an Extraneous Body that bruiseth the Part it must be taken away; and if from the wounding of a Nerve, pour into the Wound some Drops of the Oil of Lavender distill'd, which in that Case is of singular Use; this Oyl may be also taken inwardly in an appropriated Liquour, such as a {145} Decoction of Wormwood and the Tops of the lesser Centory. Balsam of _Peru_ us'd in the same Manner, is an excellent Remedy, and the Oyls of Worms, Snails, St. _John_'s-Wort and Turpentine are frequently apply'd with good Success. If the Convulsion proceeds from the Biting of some venomous Creature, Cupping-Glasses or Leeches are to be immediately applied, putting into the Wound Treacle with the Spirit of Wine or even Fire it self, and leaving to the Physician's Care the Prescription of other vulnerary Remedies proper to be taken inwardly. _What is to be done to draw the Extraneous Bodies out of a Wound?_ When they cannot be taken away with the Fingers or Forceps, the Patient must be set in the same Station or Posture wherein he was when he receiv'd the Wound, in order to get some farther Light to discover 'em; or else such Plaisters may be us'd as are endu'd with an Attractive Quality: Particularly this: Take an Ounce of Treacle, half a Dram of Gum _Ammoniack_, one Dram of _Bdellium_, and two Drams of Bore's Grease, adding a Quarter of a Pound of Wax to make 'em up into the Form of a Plaister. It is reported that Hare's Grease alone hath the same Effect, and that it goes for a Secret among the Surgeons but you may (if you please) mix it with Ointment of Betony. However it hath been observed that Leaden Bullets may sometimes remain in a Man's Body, during his whole Life-time without doing any Harm. {146} _How are Excrescences to be taken away?_ They may be consum'd with Powder of Allom, _Unguentum Ægyptiacum_, or _Lapis infernalis_. _After having remov'd every thing that hinders the reuniting of the Lips of a Wound, what is to be done to attain thereto?_ The Re-Union in Wounds is properly the Work of Nature; but it may be promoted by putting into 'em a little Balsam of _Peru_, and drawing together their Lips with the Fingers. Afterwards the Lips must be kept closed with a Bandage, a Glutinous Plaister or a dry Stitch, provided the Wound be only superficial, hindring the Air from penetrating into it. For Want of Balsam of _Peru_, an excellent one may be made with the Flowers here specified. Take the Flowers of Henbane, St. _John's-Wort_, and Comfry and let 'em be digested in the Sun during the whole Summer-Season in the Oyl of Hemp-seed, which Oyl, the longer it is kept, proves so much the better, if it be set forth in the Sun every Summer, the Vessel that contains it being well stop'd. There is also the Balsam of Balsams, or the Balsam of _Paracelsus_ call'd _Samech_. To avoid the exposing of Wounds to the Air, it is requisite to cover 'em over the Dressings with some sort of Plaister, which is usually termed the Surgeon's Plaister, such is that which is effectual in Dissolving, corroborating and allaying Pain or Inflammation. Take the Mucilages of the Roots of great Comfrey and Fenegreek, half a Pound of Ceruse or white Lead, two Drams of Crude _Opium_, one Dram of Camphire, as much of Saffron, two Drams of Sandarack, one of the Oyl of {147} Bays, one half Pound of Rosin, and as much Turpentine and Wax. Boil all these Ingredients together in a sufficient Quantity of Lin-seed-Oyl, and make a Plaister according to Art. In great Wounds it is expedient to lay over the Dressings a Cataplasm or Pultiss, such as this: Take the Leaves and Flowers of Camomile, and Melilot, the Tops of Wormwood, common Mallows and Marsh-Mallows, with the Seeds of Line and Cummin powder'd: Then boyl the whole Composition in Wine, and add thereto Barly-Meal, to give it a due Consistence. If there be any Cause to fear a Gangrene, you may also intermix Saffron, Myrrh and Aloes with Spirit of Wine. _Is it necessary to put Tents into all Wounds, and to make use of Digestives and Suppuratives?_ No: It is sufficient to procure the Re-uniting of the Parts simply by the Means of Balsam in small Wounds; because they ought not to be brought to Suppuration: so that Digestives and Suppuratives are only necessary in great Wounds, and those that are accompanied with Contusion, avoiding the ill Custom of some Country-Surgeons, that stuff up their Wounds too much with Tents and Pledgets, whereas they might well be content with simple Bolsters or Dossels which shou'd be dipt in the ordinary Digestive composed of Turpentine and the Yolks of Eggs with a little Brandy, or else with the Tincture of Myrrh and Aloes. Suppuration may also be promoted by mundifying and quickening the Wound, especially if the Bolsters be steep'd in the following Composition. {148} Take half an Ounce of Aloes and Myrrh powder'd, two Drams of _Sal Saturni_, twenty Grains of _Sal Ammoniack_, the same quantity of beaten Cloves, a Dram of Queen of _Hungary_ Water and half an Ounce of _Unguentum Basilicon_, and let the whole Mass be mingled together. In fine, the whole Mystery consists in well cleansing the Wounds with a Linnen Cloth, or with the Injections of the Tinctures of Myrrh and Aloes; or with simple Decoctions of Wormwood, _Scordium_ or Water-Germander, Bugle, Sanicle and Hore-Hound in White-Wine; as also by prescribing the Vulnerary Decoctions of Powder of Crab's-Eyes, and _Saccharum Saturni_, to be taken inwardly, to consume the acid Humours, which are a very great Obstacle that hinders the speedy cure of Wounds. _What are the Vulnerary Plants, the Decoctions of which is to be taken inwardly?_ They are _Alchymilla_ or Lion's-Foot, Ground-Ivy, _Veronica_ or Fluellin, St. _John_'s-Wort, Wormwood, Centory, Bugle, Sanicle, Chervil, and others. The Broth of Crabs may also be prescrib'd, which is an excellent Remedy, and may serve instead of a Vulnerary Potion. Sometimes Sutures or Stitches contribute very much to the re-uniting of the Lips of Wounds, when they cannot be join'd by Bandage. * * * * * {149} CHAP. III. _Of particular Wounds of the Head._ _What ought first to be consider'd in a Wound of the Head?_ Two things, that is to say, the Wound it self, and the Instrument with which it was made; for by the Consideration of the Wound, we may know whether it be Superficial or Deep; and by that of the Instrument, we are enabled to make a truer Judgment concerning the Nature of the same Wound. _What is a Superficial, and what is a Deep Wound in the Head?_ That is call'd a Superficial Wound in the Head, which lies only in the Skin; and that a Deep one which reacheth to the _Pericranium_, Skull, or Substance of the Brain. _What is to be apply'd to a Superficial Wound?_ It is cur'd with a little Queen of _Hungary_ Water; or else with a little Balsam, laying upon it the Surgeon's Plaister, or that of Betony. But if the Wound or Rent be somewhat large, it must be clos'd with a Stitch. _What is to be done to a Deep Wound?_ If it be situated in the _Pericranium_, the Wound must be kept open, waiting for Suppuration; but if it enter the Skull, an Enquiry is to be made, whether there be a Simple Contusion, or a Fracture also. In the Contusion it is necessary to wait for the Suppuration, and the {150} fall of the Splint, and to keep the Wound open; as in the Fracture, to examine whether it be in the first Table only, or in both; it is known to be only in the first, by the Application of an Instrument, and of Ink, as also in regard that there are no ill Symptoms; but a Fracture in both Tables shews it self by the Signs; and it may be found out by making a Crucial Incision in the Flesh, to discover the Fissure. _What are the Signs of the Fracture of the two Tables of the Skull, and of the overflowing of the Blood upon the Membranes of the Brain?_ They are the loss of the Understanding at the very Moment of receiving the Wound; an Hæmorrhage or Flux of Blood thro' the Nose, Mouth, or Ears; drowsiness and heaviness of the Head, and more especially Vomitting of Phlegm; from whence may be inferr'd the necessity of making use of the Trepan. _What Consequence may be drawn from the Knowledge of the Instrument with which the Wound was made?_ It is according to the Quality of this Instrument; as it is proper to cut, prick, or bruise; if it be cutting, the Wound is more Superficial, and not subject to a great Suppuration: If it be pricking, the Wound is deeper, but of small Moment: If it be a battering or bruising Instrument, the Wound is accompany'd with Contusion, producing a great Suppuration, besides the Concussion and Commotion of the Part, which are inseparable, and often cause very dangerous Symptoms. {151} Inferences may be made also from the disposition of the wounded Person; for a strong robust Man may better bear the Stroke than a weak one; and even Anger causeth an Augmentation of Vehemency; so that all such Circumstances are not to be despis'd, in regard that they give occasion to profitable Conjectures. _What particular Circumstance is there to be observ'd in undertaking the Cure of Wounds in the Face?_ It is, that a more nice Circumspection is requir'd here than elsewhere, in abstaining from Incisions, as well as in making choice of proper Medicines, which must be free from noisome Smells; and it is in this Part chiefly that Balsams are to be used, avoiding Suppuration, to prevent Scars and other Deformities. * * * * * CHAP. IV. _Of the particular Wounds of the Breast._ _What is to be observ'd in Wounds of the Breast?_ Two things, _viz._ whether they penetrate into the Cavity of the _Thorax_ or not, which may be discover'd by the Probe, and by a Wax-Candle lighted, and apply'd to the Entrance of the Wound, obliging the Patient to return to the same Posture wherein he receiv'd the Hurt, as also to keep his Nose and Mouth shut: For then the Flame may be perceiv'd to be wavering, the Orifice of the Opening being full of {152} Bubbles; a Judgment may be also made from the running out of the Blood. _What is to be done when it is certainly known that the Wound penetrates into the Cavity of the Breast?_ It is necessary to examine what Part may be hurt, by considering the situation of the Wound, and its Symptoms: If the Lungs are pierc'd, a spitting of froathy Vermilion-colour'd Blood ensues, with difficulty of Respiration, and a Cough. If any of the great Vessels are open'd, the wounded Person feels a Weight at the bottom of his Breast, is seiz'd with cold Sweats, being scarce able to fetch his Breath, and Vomits Blood, some Portion whereof issueth out of the Wound. If the _Diaphragm_ or Midriff be cut in its Tendinous Part, he is suddenly hurry'd into Convulsions: And if the Heart be wounded either in its _Basis_ or Ventricles, he falls into a Swoon, and dies incontinently. But if the Probe doth not enter, and none of the above-mentiond Symptoms appear, it may be taken for granted that the Wound is of no great Consequence. _What is to be done when the Wound penetrates into the Chest, yet none of the Parts are hurt, only there is an Effusion of Blood over the _Diaphragm_?_ It is necessary to make an _Empyema_, or otherwise the diffus'd Blood in corrupting, wou'd inevitably cause an Inflammation, Gangrene, and Death it self. _What is an _Empyema_?_ It is an Operation whereby any sorts of Matter are discharg'd with which the Diaphragm is over-spread, by making a Puncture or Opening in the Breast. * * * * * {153} CHAP. V. _Of the particular Wounds of the lower Belly._ _What is to be done to know the quality of a Wound made in the lower Belly?_ It is requisite to make use of the Probe, to observe the situation of the Wound, and to take notice of all the Symptoms: For by the help of the Probe, one may discover whether it hath penetrated into the Cavity or not, after having enjoyn'd the Patient to betake himself to the same Posture wherein he was when he first receiv'd the Wound: By its situation a Conjecture may be made that such a particular Part may be hurt; and by a due Examination of the Symptoms, one may attain to an exact Knowledge. As for Example; It is known that one of the thick Guts is open'd, when the Hurt is found in the _Hypogastrium_, and the Excrements are voided at the Wound; as it is certain that one of the thin Guts is pierc'd, when the Wound appears in the Navel, and the Chyle issueth forth from thence; and so of the others. _What Method ought to be observ'd in curing Wounds in the lower Belly?_ It is expedient at first to prevent letting in the Air, and to dilate the Wound, in order to sow up the perforated Gut, and afterward to {154} restore it to its place; as also to bind the Caul, which is let out at the opening, and to cut it off, lest in putrifying it should corrupt the neighbouring Parts. Then these Parts may be bath'd with Lees of Wine, wherein have been boil'd the Flowers of Camomile and Roses with Wormwood: The Powders of Aloes, Myrrh, and Frankincense may be also thrown upon 'em; and the Wound must be sow'd up again to dress it on the outside, the Patient in the mean time being restrain'd to a regular Diet. But Clysters must be forborn on these Occasions, especially when one of the thick Guts is wounded, making use rather of a Suppository or laxative Diet-Drinks, to avoid dilation and straining. * * * * * CHAP VI. _Of Wounds made by Guns or Fire-Arms._ These Wounds are always bruis'd and torn, with the loss of Substance, and commonly with the splitting and breaking of a Bone: They are red, black, livid, and inflam'd, not being usually accompany'd with an Hæmorrhage: They are generally round, and streighter at their Entrance than at their End; at least if they were not made with Cross-Bar-Shot, or Quarter-Pieces. {155} _Of the Prognostick of Wounds by Gun-shot._ When these Wounds penetrate into the Substance of the Brain, or Marrow of the Back-Bone, or into the Heart, _Pericardium_, great Vessels, and other noble Parts, Death always inevitably follows, and often happens at the very Instant. But one may undertake the Cure of those that are superficial, and which are made in the Neck, Shoulders, Arms, and all other parts of the Body. _Of the Cure of Wounds by Gun-shot._ For the better curing of these sorts of Wounds, it is requisite to be inform'd of the Quality of the Fire-Arms by which the Wounds were made, in regard that a Musquet is more dangerous than a Pistol, and a Cannon much more than a Musquet; as also to examine their situation and concomitant Accidents; for by how much the more complicated they are, so much the greater is the danger. Then the Patient must be set (as near as can be) in the very same Situation and Posture wherein he remain'd when the Wound was receiv'd, in order to discover the direct Passage of the Wound by the help of the Probe, with which a search is to be made, whether a Bullet, or any other extraneous Bodies, as Wood, Flocks, Linnen, or Stuff as yet stick in the Wound; so that Endeavours may be us'd to take 'em out thro' the same Hole where they enter'd, care being more especially had to avoid making {156} Dilacerations in drawing 'em out: But if the Operator hath endeavour'd to no purpose to remove these extraneous Bodies, let him make a Counter-Opening in the opposite Part, where he shall perceive any hardness, nevertheless without touching the Vessels; thus the Incision being made, he may readily draw 'em out with his Fingers, or some other Instrument. If the Bullet sticks so far in a Bone that it cannot be taken away without breaking the same Bone, it is more expedient to let it lie therein; but if the Leg or Arm-Bones are very much split or shattered, then the Amputation of 'em becomes absolutely necessary. The Pain and Inflammation of the Part may be asswag'd by letting Blood, topical Anodyns, cooling Clysters and Purgations; but in case much Blood hath been already lost, Phlebotomy must be omitted. The Clysters may be made with Decoctions of Mercury, Mallows, Beets, a Handful of Barley and Honey of Roses. Some Surgeons are of Opinion that the Patient ought to be purg'd every other Day, and even on the very same Day that he receiv'd the Wound, if his Strength will permit; however very gentle Purges are to be us'd upon this occasion, such as Cassia, Manna, Tamarins, Syrrup of Violets, and that of White Roses. In the mean while Anodyns may be compounded to mitigate the Pain; as Cataplasms or Pultisses made with the Crum of white Bread, Milk, Saffron, the Yolk of an Egg, and Oil of Roses us'd hot; which last Ingredient is of it self a very good Anodyn. But to asswage great Inflammations, Oil of {157} Roses, the White of an Egg and Vinegar beaten all together, may be laid on the neighbouring Parts. At first it is necessary to apply spirituous Medicines to the Wound, and Pledgets steep'd in camphirated Brandy, are admirable for that purpose; but if there be a Flux of Blood, styptick Waters, or other astringent Remedies may be us'd, still remembring that all these Medicaments must be apply'd hot. To promote the Suppuration of these contused Wounds, a Digestive may be made of _Oleum Rosatum_, the Yolk of an Egg, and _Venice_ Turpentine. If the Wound be in the Nerves, Tendons, or other Nervous Parts, it is requisite to use spirituous and drying Medicines, never applying any Ointments, which will not fail to cause Purtrefaction in those Parts: But a Cataplasm may be made with Barley-Meal, _Orobus_, Lupins and Lentils boil'd in Claret, adding some Oil of St. _John_'s-Wort. The Balsam of _Peru_, Oil of Turpentine destill'd, Oil of Wax, destill'd Oil of Lavender, _Oleum Philosophorum_, Oil of Bays destill'd, Balsam of St. _John_'s-Wort, Spirit of Wine, and Gum _Elemi_, are excellent Medicaments for the Nerves: Or else, Take four Ounces of _Unguentum Althææ_ with a Dram and a half of destill'd Bays; mingle the whole Composition, and apply it: Or else, Take an Ounce of destill'd Oil of Turpentine, a Dram of Spirit of Wine, and half an Ounce of Camphire; let all be intermixt, and dropt into the Wound: Or else, {158} Take a Scruple of _Euphorbium_, half an Ounce of _Colophonia_, and a little Wax; let 'em be mingl'd together, and apply'd very hot to the Nervous Parts. If the Wounds are deep, Injections may be made with this Vulnerary Water, which is very good for all sorts of Contusions, as also for the Gangrene and Ulcers. Take the lesser Sage, the greater Comfrey, and Mugwort, of each four Handfuls; Plantane, Tobacco, Meadowsweet, Betony, Agrimony, Vervein, St. _John_'s-Wort, and Wormwood, of each three Handfuls; Fennel, Pilewort Bugle, Sanicle, Mouse-Ear, the lesser Dazy, the lesser Centory, and All-heal, of each three Handfuls; three Ounces of round Birth-Wort, and two Ounces of long: Let the whole Composition be digested during thirty Hours, in two Gallons of good White-Wine, and afterward destill'd in _Balneo Mariæ_, till one third part be consumed. If a Gangrene happens in the Part, Spirit of Mother-Wort may be put into it, which is compounded with two Drams of Mastick, Myrrh, _Olibanum_, and Amber, and a Quart of rectify'd Wine, the whole being destill'd. This Fomentation may be apply'd very hot to very good purpose, _viz._ an equal quantity of Camphirated Wine and Lime-Water, with three Drams of Camphire. This is also an excellent Cataplasm: Take a Pint of Lye, and as much Spirit of Wine, half an Handful of Rue, Sage, _Scordium_, and Wormwood, a Dram of each of the Roots of both sorts of Birth-Wort, and two Drams of {159} _Sal Ammoniack_. Let the whole Composition be boil'd till a third Part be consum'd; adding half a Dram of Myrrh and Aloes, and a little Brandy. _Of a Burn made by Gun-Powder._ If the Burn be recent, and the Skin not exulcerated, Spirit of Wine or Brandy is to be immediately apply'd; or else an Ointment may be made with Oil of Olives, or bitter Almonds, Salt, the Juice of Onions, and Verjuice. If the Skin be ulcerated, and little Bladders or Pustules arise, an Ointment may be compounded with the second Bark of Elder boil'd in Oil of Olives. After it hath been strain'd, add two parts of Ceruse or White-Lead, and one of Burnt Lead, with as much Litharge, stirr'd about in a Leaden-Mortar, to make a Liniment. But it is not convenient to take out the Grains of Powder that remain in the Skin, because they are apt to break, and to be more confounded or spread abroad; so that they must be left to come forth in the Suppuration. When the Wound is superficial, and the Skin as yet whole, peel'd Onions with common Honey are an excellent Remedy; but if the Skin be torn, it is not to be us'd, by reason that the Pain wou'd be too great; in which case Oil of Tartar _per diliquium_ hath a very good effect. If the Burn be accompany'd with a Fever, it may be allay'd with fixt Nitre, Nitre {160} prepar'd with Antimony, and Gun-Powder taken inwardly, which are very effectual in their Operation. Crab's-Eyes prepar'd, and even some of 'em unprepar'd, are in like manner admirable Remedies. As for external Medicaments, when the Burn is only superficial, take Onions and unslack'd Lime, quench'd in a Decoction of Rapes, and apply this Liquor very hot, with double Bolsters dipt therein. Or else take what quantity you please of quick Lime well wash'd, and pound it thoroughly in a Leaden-Mortar, with May-Butter without Salt, to make an Ointment, which may be laid altogether liquid upon the affected Part: Or else, Take as much quick Lime as you can get up between your Fingers at two several times; Milk-Cream and clarify'd Honey, of each about half the like quantity; let the whole be intermix'd to the Consistence of an Ointment, and apply'd: It is an approv'd Remedy; as also is the following; Take unslack'd Lime, and put it into common Water, so as the Water may appear four or five Finger's breadth above it. After the Effervescence, pour in Oil of Roses; whereupon the whole Mass will be coagulated in form of Butter, and may be apply'd. A good Lotion or Washing-Liquor may be prepar'd with the Juice of Garlick and Onions, in recent Burns; otherwise make use of this Ointment. Take an Ounce and an half of raw Onions, Salt, and _Venice_ Soap, of each half an Ounce; mingle the whole Composition in a Mortar, pouring upon it a sufficient {161} quantity of Oil of Roses, to make a very good Ointment: Or else, Dissolve _Minium_ or Litharge in Vinegar, filtrate this Liquor, and add thereto a quantity of Rape-Oil newly drawn off, sufficient to give it the Consistence of a liquid Liniment; then stir it about in a Leaden-Mortar till it become of a grey Colour, and keep it for Use as an excellent Liniment: Or else, Pound Crey-Fishes or Crabs alive in a Mortar to get their Blood, and foment the Part with it hot; it is a good Remedy: Otherwise intermix the pounded Crabs with May-Butter without Salt, and let 'em be boil'd up together, and scumm'd, till a red Ointment be made, which may be drawn off, or strain'd for Use. And indeed, all manner of Ointments, and other Medicinal Compositions wherein Crabs are an Ingredient, are true specificks against Burns made by Gun-Powder. The Mucilages of the Seeds of _Psyllium_, or rather those of Quince-Seeds prepar'd with Frog's Sperm, and a little _Saccharum Saturni_, spread with a Feather upon the affected Part, have a wonderful Operation in Burns. A Medicament compounded with one third part of the Oil of Olives, and two of the Whites of Eggs well beaten and mixt together, is a very simple and singular Remedy. Otherwise take half an Ounce of Line-seed-Oil infus'd in Rose-Water, with four Yolks of Eggs; beat 'em together, and let the whole be apply'd to the burnt Part. If the Burn be very violent, and hath many Pustules, _Etmullerus_ is of Opinion that they {162} ought to be open'd, and that an Ointment shou'd be apply'd, which is made of Hen's-Dung boil'd in fresh Butter: Otherwise, Take a handful of fresh Sage-Leaves, two handfuls of Plantane, six Ounces of fresh Butter without Salt, three Ounces of Pullet's-Dung newly voided, and the whitest that can be found; then fry the whole Composition for a quarter of an Hour; squeeze it out, and keep it for use: Otherwise, Take two Ounces of sweet Apples roasted under Embers, Barly-Meal, and Fenugreek, of each half an Ounce, and half a Scruple of Saffron; let the whole Mass be mingled to make a Liniment or soft Cataplasm, which may serve to asswage Pain, and mollifie the Skin. If the Wound be yet larger, and hath a Scab, open all the Pustules, and endeavour the two first Days to cause the Escar to fall off by the Application of a Liniment made of the Mucilages of Quince-Seeds steept in Frog's-Sperm, with fresh Butter, the Oil of White Lillies, and the Yolk of an Egg: Otherwise, Make a Liniment with fresh Butter well beaten in a Leaden-Mortar, with a Decoction of Mallows, which being spread upon hot Colewort-Leaves, and apply'd to the Escar, it will fall off. But if the Escar be too hard and obstinate, it is requisite to proceed to Incisions to make way for the _Sanies_, lest a deep and putrid Ulcer shou'd be engender'd Underneath. As soon as the Humour is evacuated, the above-mention'd {163} Emollient Medicines may be us'd, till the separation of the Escar; then the Ulcer may be consolidated with Digestives and Mundificatives; such as the Ointment of quick Lime with Oil of Roses, and the Yolks of Eggs. The white camphirated Ointments, and that of Alabaster, are also good for the same Purpose. If a Gangrene ensueth, Sudorificks must be taken inwardly; such are camphirated Spirit of Treacle, the Essence and Spirit of Elder-Berries, the Spirit of Hart's-Horn with its own proper Salt, Treacle impregnated with the Spirit of camphirated Wine, Scorpion-Water, Hart's-Horn, Citron with Camphire, &c. As for external Remedies in the beginning of the Gangrene, the Spirit of Wine apply'd hot is excellent; and yet better if Aloes, Frankincense, and Myrrh be intermixt therein. It ought also to be observ'd, that Camphire must always be mingled in the topical Medicines for the Cure of the Gangrene. A Decoction of unslack'd lime, in which Brimstone hath been boil'd, with _Mercurius Dulcis_, and the Spirit of Wine, is a very efficacious Remedy. In a considerable Gangrene, after having made deep Scarifications, let Horse-Dung be boil'd in Wine, and laid upon the Part in form of a Cataplasm. This is an approved Remedy. If a _Sphacelus_ be begun, scarifie the Part, and apply thereto abundance of _Unguentum Ægyptiacum_ over and above the Ointments and Cataplasms already describ'd; remembring {164} always, that when the Gangrene degenerates into a _Sphacelus_, all the mortify'd Parts must be incontinently separated or cut off from the sound. * * * * * CHAP. VII. _Of Ulcers in general._ _What is an Ulcer?_ An Ulcer is a Rupture of the Natural Union of the Parts made a long while ago, which is maintain'd by the _Sanies_ that runs out of its Cavity; or an Ulcer takes its Rise from a Wound that cou'd not be well cur'd in its proper time, by reason of the ill quality of its _Pus_ or corrupt Matter. _What difference is there between a Wound and an Ulcer?_ It is this, that a Wound always proceeds from an external Cause, and an Ulcer from an internal, such as Humours that fall upon a Part; or else a Wound in growing inveterate degenerates into an Ulcer. _Whence is the difference of Ulcers deriv'd?_ It is taken from the Causes that produce 'em, and the Symptoms or Accidents with which they are accompany'd. Thus upon Account of their Causes they are call'd Benign or Malignant, Great, Little, Dangerous, or Mortal; and by reason of their Accidents, they are term'd Putrid, Corrosive, Cavernous, Fistulous, Cancerous, _&c._ {165} _Do Ulcers always proceed from external Causes, or from an outward Wound degenerated?_ No they sometimes also derive their Origine from internal Causes, as the Acrimony of Humours, or their Malignant Quality; the Retention of a Splint of a Bone, and other things of the like Nature. These Ulcers are commonly call'd Primitive, and the others Degenerate. _What are Putrid, Corrosive, Cavernous, Fistulous and Cancerous Ulcers?_ The Putrid Ulcer is that wherein the Flesh is soft and scabby, the _Pus_ and _Ichor_ being viscous, stinking, and of a cadaverous smell. The Corrosive Ulcer is that which by the Acrimony and Malignity of its _Sanies_, corrodes, makes hollow, corrupts and mortifies the Flesh. The Cavernous Ulcer is that the Entrance of which is streight and the bottom broad wherein there are many Holes fill'd with malignant _Sanies_, without any callosity or hardness in its sides. The Fistulous Ulcer is that which hath long, streight, and deep Holes, with much hardness in its sides; the _Sanies_ whereof is sometimes virulent, and sometimes not. The Cancerous Ulcer is large, having its Lips bloated, hard, and knotty, of a brown Colour, with thick Veins round about, full of a livid and blackish sort of Blood. In the bottom are divers round Cavities, which stink extremely, by reason of the ill Quality of the _Sanies_ that runs out from thence. _Are there no other kinds of Ulcers?_ {166} Yes, there are also Verminous, _Chironian_, _Telephian_, Pocky, Scorbutick, and others, which have much affinity with, and may well be reckon'd among the five Kinds already specify'd. _What are the means to be us'd in the curing of Ulcers?_ Ulcers ought to be well mundify'd, dry'd and cicatriz'd; but with respect to the several Causes and Accidents that render 'em obstinate, and difficult to be cur'd, it is also requisite to make use of internal Medicines, which may restrain and consume 'em. If their sides grow callous, they are to be scarify'd, in order to bring 'em to Suppuration; and if there be any Excrescences, they must be eaten away with corroding Powders, such as that of Allom; or by the Infernal Cautery. _What are the Remedies proper to cleanse and dry up Ulcers?_ To this Purpose divers sorts of Liquors may be us'd, as also Powders and Plaisters: The Liquors are usually made of Briony-Roots, the greater Celandine, Lime, and Yellow Water; a Tincture of Myrrh, Aloes and Saffron, and Whey, whereto is added _Saccharum Saturni_; so that the Ulcers may be wash'd or bath'd with these Liquors; and very good Injections may be compounded of 'em. The Powders are those of Worm-eaten-Oak, Allom, and Cinoper, the last of these being us'd by burning it, to cause the Fume to be convey'd to the Ulcer thro' a Funnel. The Country People often make use of Potter's-Earth to dry up their Ulcers, with good {167} Success; but then they must must be of a Malignant Nature. The Plaisters are _Emplastrum de Betonica_, _Diasulphuris_, _Dessiccativum Rubrum_, and others; and the Ointments are such as these; Take three Yolks of Egg, half an Ounce of Honey, and a Glass of Wine, and make thereof a mundifying Ointment, according to Art: Otherwise, Take Lime well wash'd and dry'd several times, let it be mingled with the Oil of Line and _Bolus_, and it will make an excellent Ointment to mundifie and dry; a little _Mercury Precipitate_ may be intermixt (if you please) to augment the drying Quality; and _Mercurius Dulcis_ may be added in the Injections. For Ulcers in the Legs, and Cancerous Ulcers, take Plantain-Water and Allom-Water, or else Spirit of Wine, _Unguentum Ægyptiacum_, and Treacle; or else an Extract of the Roots of round Birth-Wort made in the Spirit of Wine. Gun-Powder alone dissolv'd in Wine, is of singular Use to wash the Ulcers, and afterwards to wet the Pledgers which are to be apply'd to 'em. But here are two particular and specifick Medicines to mollifie a Cancer. Take _Saccharum Saturni_, Camphire, and Soot; let 'em be incorporated with the Juice of House-Leek and Plantain, in a Leaden-Mortar; then make a Liniment thereof, and cover the Part affected as lightly as is possible to be done, as with a simple Canvass-Cloth, or a Sheet of Cap-Paper: Or else, {168} Take the destill'd Water of rotten Apples, and mingle it with the Extract of the Roots of round Birth-Wort made in Spirit of Wine; reserving this Liquor to wash the Part, and to make Injections. * * * * * CHAP. VIII. _Of Venereal Diseases._ _Of the _Chaude-pisse_ or _Gonorrhæa_._ The Signs of this Disease are a painful Distention of the _Penis_ or Yard, and a scalding Pain in making Water, the Urine being pale, whitish, and full of Filaments or little Threads: Sometimes the Testicles are swell'd as well as the _Glans_ and _Præputium_; and sometimes there is a Flux of a kind of Matter yellowish, Greenish, _&c._ If there be a great Inflammation in the Yard, endeavours must be us'd to allay it by letting Blood; and afterward the Patient may take a cooling and diuretick Diet-Drink, as also Emulsions made with cold Seeds in Whey. A very good Decoction may be prepar'd in all places, and without any trouble, by putting a Dram of _Sal Prunella_ into every Quart of Water, whereof the Patient is to drink as often as he can: This Decoction is very cooling and diuretick; and the use of it ought to be continu'd till the Inflammation be asswag'd. Then some gentle {169} Purges are to be prescrib'd in the beginning; such as an Ounce of _Cassia_, and as much _Manna_, infus'd in two Glasses of Whey, which are to be taken one or two Hours one after another. Afterward the Patient must be often purg'd with twelve Grains of Scammony, and fifteen Grains of _Mercurius Dulcis_; and these Purgations must be continu'd, till it appears that the Fluxes are neither yellowish nor greenish, nor of any other bad Colour. When they are become White, and grown Thready, they may be stopt with Astringents: Amber and dry'd Bones beaten to Powder, eighteen Grains of each, with one Grain of _Laudanum_, the Composition being taken in Conserve of Roses, are very good for this Purpose. _Crocus Martis Astringens_, or else its Extract, taken from half a Dram to a whole Dram, in like manner performs the same Operation. As soon as the _Gonorrhæa_ is stopt, to be certain of a perfect Cure, a Dram of the _Mercurial Panacæa_ is to be taken, from fifteen to twenty Grains at a time, in Conserve of Roses. In the mean while, if a small Salivation shou'd happen, it must be let alone for the present, since it may be stopt at pleasure by the Purgations. When it is requisite to restrain the _Gonorrhæa_, _Mercury_ must not be given any longer, in regard that it is a Dissolvent, which is only good when the Glandules of the Groin or Testicles are swell'd, or else when it is expedient to set the _Chaude-pisse_ a running, after it hath been too suddenly stopt. At the same time that the Astringents are taken with the Mouth, {170} Injections also are to be made into the Yard; such as are prepar'd with _Lapis Medicamentosus_, of which one Dram is put into eight Ounces of Plantane-Water. All Astringents that are not Causticks, are proper for the Syringe. _Of Shankers._ They are round Ulcers, and hollow in the middle, which appear upon the _Glans_ and the _Præputium_. To cure 'em, they must be touch'd with the _Lapis Infernalis_, and brought to Suppuration by the means of red Precipitate mixt with the Ointment of _Andreas Crucius_. _Oleum Mercurii_ laid on a Pledget or Bolster, is very efficacious to open Skankers, and consume their Flesh. The Patient must be well purg'd with _Mercurius Dulcis_ and Scammony, taking twelve or fifteen Grains of each in Conserve of Roses; and after these Purgations are sufficiently reiterated, he may take the _Mercurial Panacæa's_. It is an excellent Remedy for all sorts of Pocky Distempers not yet consummated, or arriv'd at the greatest height of Malignity. _Of _Bubo_'s._ _Bubo's_ are gross Tumours or Abcesses that arise in the Groin, the perfect Maturity of which is not to be waited for in order to open 'em; because it is to be fear'd lest the corrupt Matter remaining therein too long, might be convey'd into the Blood by the Circulation, and so produce the grand Pox: Therefore it is {171} necessary to open 'em betimes with a Lancet, or else with a Train of potential Cauteries, if they are too hard. They ought to be Suppurated for a considerable time: The Patient must be well purg'd with Scammony and _Mercurius Dulcis_: He must also take the _Mercurial Panacæa's_. _Of the Pox._ This loathsome Disease begins sometimes with a virulent _Gonorrhæa_, and a weariness or faintness at the same time seizeth on all the Members of the Body: It is usually accompany'd with Salivation and the Head-ach, which grows more violent at Night: Pricking Pains are also felt in the Arms and Legs, the Palate of the Mouth being sometimes ulcerated. If it be an inveterate Pox, the Bones are corrupted, and _Exostoses_ happen therein; divers Spots with dry, round and red Pustules appear in the Skin; and the Cartilages or Gristles of the Nose are sometimes eaten up. But when this Disease is come to its greatest height of Malignity, the Hair falls off; the Gums are ulcerated; the Teeth are loose, and drop out; the whole Body is dry'd up; the Eyes are livid; the Ears tingle; the Nose become stinking; the Almonds of the Ears swell; the _Uvula_ or Palate is down; Ulcers break out in the Privy-Parts; Bubo's arise in the Groin; as also Warts in the _Glans_ and _Præputium_; and _Condyloma's_ in the _Anus_. Indeed the Pox may be easily cur'd in the beginning; but when it hath taken deep Root {172} by a long Continuance, it is not extirpated without much difficulty, more especially if it be accompany'd with Ulcers, _Caries_, and _Exostoses_; the Person afflicted with it being of an ill Constitution, and his Voice grown hoarse. The Spring and Summer are the proper Seasons of the Year for undertaking the Cure of this Disease: In order to which, it is necessary that the Patient begin with a regular Diet, lodging in a warm place, and taking such Aliments as yield a good Juice; as Jelly-broath made with boil'd Fowl: Let him drink Sudorifick Decoctions, prepar'd with the Wood of _Guayacum_, _China_-Root, and _Sarsaparella_, and let him abstain from eating any thing that is high season'd: Let him take Clysters to keep his Body open; sometimes also he may be let Blood, and purg'd with half a Dram of Jalap, and fifteen Grains of _Mercurius Dulcis_. The Purgations may be re-iterated as often as it shall be judg'd convenient; and then the Patient may be bath'd for nine or ten Days, every Morning and Evening; during which time he may take volatile Salt of Vipers, the Dose being from six to sixteen Grains; or else Viper's-Grease from half a Dram to a whole Dram in Conserve of Roses. Afterward it will be necessary to proceed to Fluxing, which is caus'd by the means of Frictions with _Vuguentum Mercurii_, which is made of crude _Mercury_ stirr'd about in a Mortar with Turpentine, and then the whole mingled with Hog's-Grease, one part of _Mercury_ being usually put into two parts of Hog's-Grease. The Rubbing is begun at the Sole of the Feet, {173} by a long Continuance, it is not extirpated without ascending to the Legs, and the inside of the Thighs; but the Back-Bone must not be rubb'd at all; When the Persons are tender, or of a weak Constitution, a single Friction may be sometimes sufficient. Thus the Patient must be rubb'd at the Fire, after he hath taken a good Mess of Broath; but I would not advise it to be done with more than one or two Drams of _Mercury_ at a time, without reckoning the Grease. Then the Patient must be dress'd with a Pair of Linnen-Drawers or Pantaloons, and laid in his Bed, where his Mouth may be lookt into from time to time, to see whether the _Mercury_ hath taken effect; which may be easily known, by reason that his Tongue, Gums, and Palate swell and grow thick, his Head akes, his Breath is strong, his Face red, and he can scarce swallow his Spittle; or else he begins to Salivate. If none of these Signs appear, the Rubbing must be begun again in the Morning and Evening; then if no Salivation be perceiv'd, for sometimes four or five Frictions are made successively, a little _Mercurial Panacæa_ may be taken inwardly, to promote it. During the Frictions, the Patient is to be nourish'd with Eggs, Broaths, and Gellies; he must also keep his Bed in a warm Room, and never rise till it shall be thought fit to stop the Salivation, which continues twenty or twenty five Days; or rather till it becomes Laudable; that is to say, till it be no longer stinking, nor colour'd, but clear and fluid. If a Looseness shou'd happen during the Salivation, it wou'd cease, so that to renew it, {174} the Looseness may be stay'd with Clysters made of Milk and the Yolks of Eggs; and in case the Salivation shou'd not begin afresh, it must be excited with a slight Friction: But if it shoul'd be too violent, it may be diminish'd by some gentle Purge, or with four or five Grains of _Aurum Fulminans_, taken in Conserve of Roses. Three or four Pints of Rheum are commonly salivated every Day in a Bason made for that purpose, which the Patient holds in his Bed near his Mouth, so as the Spittle may run into it. But if the Fluxing shou'd not cease of it self at the time when it ought, he must be purg'd to put a stop thereto. If any Ulcers remain in his Mouth, to dry 'em up, Gargarisms are to be often us'd, which are made of Barley-Water, Honey of Roses, or luke-warm Wine. The Warts are cur'd by binding 'em, if a Ligature be possible, or else they may be consum'd with Causticks, such as the Powder of Savine, or _Aqua-fortis_, by corroding the neighbouring Parts; sometimes they are cut, left to bleed for a while, and bath'd with warm Wine. When the Patient begins to rise, he must be purg'd, his Linnen, Bed, and Chamber being chang'd; and afterward his Strength is to be recruited with good Victuals, and generous Wine. If he were too much weaken'd, let him take Cow's-Milk with _Saccharum Rosatum_. If the Pox were not inveterate, the Fluxing might be excited by the _Panacæa_ alone, without any Frictions: For after the Phlebotomy, {175} Purgations, and Bathings duly administer'd; the Patient might take ten Grains of the _Mercurial Panacæa_ in the Morning, and as many at Night; on the next Day fifteen Grains might be given, and the like quantity at Night; on the third Day twenty Grains might be given both Morning and Evening; on the fourth Day twenty five Grains in the Morning, and as many at Night; and on the fifth Day thirty Grains in the Morning, and the very same quantity in the Evening; continuing thus to augment the Dose, till the Fluxing comes in abundance; and it may be maintain'd by giving every two or every three Days twelve Grains of the _Panacæa_. This Course must be continually follow'd till the Salivation becomes Laudable, and the Symptoms cease. _The manner of making the _Mercurial Panacæa_._ To prepare this _Panacæa_, it is requisite to take _Mercury_ reviv'd from _Cinnabar_, because it is more pure than _Mercury_ which is immediately dug out of the Mine. The _Mercury_ is reviv'd with _Cinnabar_, after this manner: Take a Pound of artificial _Cinnabar_ pulveriz'd, and mingled exactly with three Pounds of unslack'd Lime, in like manner beaten to Powder: Let this Mixture be put into a Retort of Stone, or Glass luted, the third part of which at least remains empty; Let it be plac'd in a reverberating Furnace; and after having fitted a Recipient fill'd with Water, let the whole be left during twenty four Hours at least; then let the Fire be {176} put under it by degrees, and at length let the Heat be very much augmented, whereupon the _Mercury_ will run Drop by Drop into the Recipient: Let the Fire be continu'd till nothing comes forth, and the Operation will be perform'd generally in six or seven Hours: Then pour the Water out of the Recipient, and having wash'd the _Mercury_, to cleanse it from some small quantity of Earth that may stick thereto, let it be dry'd with Cloaths, or else with the Crum of Bread: Thus thirteen Ounces of _Mercury_ may be drawn off from every Pound of artificial Cinnabar. The _Panacæa_ is made of sweet Sublimate, and the later of corrosive Sublimate: To make the corrosive Sublimate, put sixteen Ounces of _Mercury_ reviv'd from Cinnabar, into a Matrass, pour upon it eighteen Ounces of Spirit of Nitre; place the Matras upon the Sand, which must be somewhat hot, and leave it there till the Dissolution be effected: Then pour off this dissolved Liquor, which will be as clear as Water, into a Glass Vial, or into a Stone-Jug, and let its Moisture evaporate gently over the Sand-Fire, till a white Mass remains; which you may pulverize in a Glass Mortar, mingling it with sixteen Ounces of Vitriol calcin'd, and as much decrepited Salt: Put this Mixture into a Matras, two third parts of which remain empty, and the Neck of which hath been cut in the middle of its height; then fix the Matras in the Sand, and begin to kindle a gentle Fire underneath, which may be continu'd for three Hours; afterwards let Coals be thrown upon it till the Fire burn very vehemently, and a Sublimate {177} will arise on the top of the Matras; so that the Operation may be perform'd within the space of six or seven Hours. Let the Matras be cool'd, and afterward broken; avoiding a kind of Flower or light Powder, which flyes up into the Air as soon as this Matter is remov'd; whereupon you'll find nineteen Ounces of very good corrosive Sublimate; but the red _Scoria_ or Dross which settleth at the bottom must be cast away as unprofitable. This Sublimate being a powerful _Escarotick_, eats away proud Flesh, and is of singular use in cleansing old Ulcers. If half a Dram thereof be dissolv'd in a Pint of Lime-Water, it gives a yellow Tincture; and this is that which is call'd the _Phagedonick-Water_. The sweet Sublimate, of which the _Panacæa_ is immediately compos'd, is made with sixteen Ounces of corrosive Sublimate, pulveriz'd in a Marble or Glass-Mortar, intermixing with it by little and little, twelve Ounces of _Mercury_ reviv'd from Cinnabar: Let this Mixture be stirr'd about with a Wooden Pestle, till the Quick-silver become imperceptible; then put the Powder, which will be of a grey Colour, into divers Glass-Vials, or into a Matras, of which two third parts remain empty; place your Vessel on the Sand, and kindle a small Fire in the beginning, the Heat of which may be afterward encreas'd to the third Degree: Let it continue in this Condition till the Sublimate be made; and the Operation will be generally consummated {178} in four or five Hours: whereupon you may break your Vial, and throw away as useless, a little light Earth that lies at the bottom. You must also separate that which sticks to the Neck of the Vials, or of the Matras, and keep it for Ointments against the Itch; but carefully gather together the white Matter which lies in the middle, and having pulveriz'd it, cause it to be sublimated in the Vials or Matras, as before. This Matter must also be separated again (as we have already shown) and put into other Vials to be sublimated a third time. Lastly, the terrestrial parts in the bottom, and the fuliginous in the Neck of the Vials, must be, in like manner, separated, still preserving the Sublimate in the middle, which will then be very well dulcify'd, and amount to the quantity of twenty five Ounces and an half: It is an Efficacious Remedy for all sorts of Venereal Diseases; removes Obstructions, kills Worms, and purgeth gently by stool, being taken in Pills from six Grains to thirty. _Of the proper Composition of the _Mercurial Panacæa_._ Take what quantity you please of sweet Sublimate, reduce it to Powder in a Marble or Glass-Mortar, and put it into a Matras, three quarters whereof remain empty, and of which you have cut off the Neck in {179} the middle of its Height: Then place this Matras in a Furnace or _Balneum_ of Sand, and make a little Fire underneath for an Hour, to give a gentle Heat to the Matter, which may be augmented by little and little to the third degree: Let it continue in this state about five Hours, and the Matter will be sublimated within that space of time. Then let the Vessel cool, and break it, throwing away as unprofitable a little light sort of Earth, of a reddish Colour, which is found at the bottom, and separating all the Sublimate from the Glass. Afterward pulverize it a second time, and let it be sublimated in a Matras, as before: Thus the Sublimations must be reiterated seven several times, changing the Matrasses every time, and casting away the light Earth. Then having reduc'd your Sublimate to a very fine impalpable Powder, by grinding it upon a Porphyry or Marble Stone, put it into a Glass Cucurbite or Gourd, pour into it alkaliz'd Spirit of Wine to the height of four Fingers; cover the Cucurbite with its Head, and leave the Matter in Infusion during fifteen Days, stirring it about from time to time with an Ivory _Spatula_. Afterward set your Cucurbite in _Balneo Mariæ_, or in a Vaporous Bath, make fit a Recipient to the Mouth of the Alembick; lute the Joints exactly with a moistened Bladder, and cause all the Spirit of Wine to be destill'd with a moderate Fire: Let the Vessels be cool'd, and unluted, and the _Panacæa_ will appear at the bottom of the Cucurbite. If it be not {180} already dry enough, you may dry it up with a gentle Fire in the Sand, stirring it with an Ivory or Wooden _Spatula_ in the Cucurbite it self till it be reduc'd to Powder. It may be kept for use in a Glass-Vessel, as a Remedy of very great Efficacy for all sorts of Venereal Diseases, as also for Obstructions, the Scurvy, _Scrophula_ or Kings-Evil, Tettar, Scab, Scurf, Worms, _Ascarides,_ inveterate Ulcers, _&c._ The Dose is from six Grains to two Scruples, in Conserve of Roses. * * * * * {181} A TREATISE OF THE DISEASES OF THE BONES. * * * * * CHAP. I. _Of the Dislocation of the Bones._ _What are the Diseases incident to the Bones?_ They are five in number, _viz._ Dislocation, Fracture, _Caries_ or Ulcer, _Exostosis_, and _Nodus_. _What is a Dislocation or Luxation?_ It is the starting of the Head of one Bone out of the Cavity of another, with an {182} Interdiction of the proper Motion of the Part: Or else it is the disjointing of two Bones united together for the Motion of a Part. _How many causes are there of Dislocation in general?_ Two, that is to say, one violent, and the other gentle; thus the Dislocation is made violently in Falls, Strains, Knocks, and Blows; but it is done gently and slowly in Defluctions of Rheum; as also by an insensible gathering together of Humours between the Joints, and upon the Ligaments, the Relaxation or loosening of which gives occasion afterward to the Head of the Bone to go out of its place; whence this Consequence may well be drawn, _viz._ that a violent Dislocation usually depends upon an external Cause, and a gentle Dislocation upon an internal. _After how many manners doth a Dislocation happen?_ Two several Ways; _viz._ the first is called compleat, total, and perfect; and the second incompleat, partial, and imperfect: But both may happen before, behind, on the inside, and without; and may also be simple or complicated. _What are the signs of a perfect, total, and compleat Dislocation?_ It is when a hard Tumour or Swelling is perceiv'd near a Hole in the place of the Joint, great pain being felt in the Part, and the Motion of it abolish'd. _What are the signs of an imperfect, partial, and incompleat Dislocation?_ {183} It is when the Motion is streighten'd, and weaker than ordinary, so that some Pain is felt in the Joynt, and a Deformity may be discern'd therein, by comparing the hurt Part with the opposite which is found: This Dislocation is otherwise call'd a Sprain, when it proceeds from an external Cause; or else it is termed a Relaxation, when it happens by an internal. _What is a simple, and what is a complicated Dislocation or Luxation?_ The Dislocation is properly simple, when it hath no concomitant Accidents; and it is complicated when accompany'd with some ill Symptoms or Accidents, such as Swellings, Inflammations, Wounds, Fractures, &c. _What are the means proper to be us'd in a simple Dislocation?_ A speedy and simple reducing thereof, which is perform'd by stretching out the dislocated or luxated Member, and thrusting back the Head of the Bone into its natural place. Afterward the Joynt must be strengthen'd with a Fomentation made with Provence Roses, the Leaves of Wormwood, Rosemary, Camomile, St. _John_'s-Wort, and Oak-Moss boil'd in the Lees of Wine and Forge-Water, keeping the Part well bound up, and sustain'd in a convenient situation. But if any ill Consequence is to be fear'd, apply _Emplastrum Oxycroceum_, or _Diapalma_ dissolv'd in Wine. _What is to be done in a complicated Dislocation?_ {184} The Accidents must be first remov'd, and then the Bone may be set, which is impossible to be done otherwise; it being dangerous even to make an Attempt before, by reason of the too great Violence with which it is effected, and which would infallibly produce a Convulsion or a Gangrene. _If the Dislocation be accompany'd with a Wound, must the Wound be cur'd before any Endeavours are us'd to reduce it?_ No, but the Symptoms of the Wound, which hinder the Operation, must be taken away, as the Swelling, Inflammation, and others of the like Nature; and then it may be reduc'd, and the Wound may be dress'd according to the usual Method. _If the Dislocation be complicated with the Fracture, what is to be done then?_ It is necessary to begin with reducing of the Dislocation, and afterward to perform that of the Fracture, by reason of the Extension which must be made to reduce the Dislocation, which would absolutely hinder the Setling of the Fracture. _How is the Inflammation and Swelling to be asswag'd?_ With Linnen Cloaths dipt in Brandy and common Water, which must be often renew'd; or else with the Tops of Wormwood and Camomile, with Sage and Rosemary boil'd in the Lees of Wine, wherein the Bolsters and Bands are to be steep'd. But all Repercussives and Astringents must be avoided. _How doth it appear that the Reduction is well perform'd?_ {185} By the Re-establishment of the Part in its natural State; by its being free from Pain; by its regular Motion; and by its conformity to the opposite Part which is found. _What Dislocations of Parts are most difficult to be reduc'd?_ They are those of the Thighs with the Huckle-Bones, which are almost never perfectly set; that of the first _Vertebra's_ is extremely difficult to be reduc'd; and those of the Lower-Jaw and Soles of the Feet are mortal. The reducing of Dislocations is perform'd with greater facility in Infants than in Persons advanc'd in Years; but it becomes most difficult when it is deferr'd for many Days, by reason of the overflowing of the _Lympha_ and nutritious Juice. If an Inflammation shou'd happen before the Member is reduc'd, nothing can be done till it be allay'd, as we have already intimated; but to prevent and mitigate it, the dislocated Joynt, and the neighbouring Parts, may be bath'd with luke-warm Wine, in which hath been boil'd the Tops of St. _John_'s-Wort, Camomile, Rosemary, _Stoecas Arabica_, and other Ingredients of the like Nature; the Bands must be also steept in the same Liquor. If an _Oedematous_ Tumour arise in the luxated Member after the Joint hath been set, it is requisite to take internal Sudorificks, and to apply Liniments made with the destill'd Oil of Tartar, and of Human Bones, which may be rectify'd with burnt Hart's Horn, or some other part of Animals, to take away its stink: Or else take yellow-Wax, and very white Rosin, {186} melt the whole Mass, and put into it white Amber and Gum _Elemi_, a sufficient quantity of each to make a Composition to be incorporated with Balsam of _Peru_; a Plaister of which may be prepar'd, and apply'd to the dislocated Member; but the Plaister must not be laid a cross, lest it shou'd contract the Part too much. The whole Member may be also anointed with Oil of St. _John_'s-Wort, or with the destill'd Oil of Turpentine; or rather with a simple Decoction of Nervous Plants in Wine. If the Bone be put out of its place by a coagulated sort of Matter like Mortar or Plaister, Resolutives and Attenuants are to be us'd, such as the volatile Spirit of Tartar prepar'd with the Lees of Wine, volatile Spirit of Tartar destill'd with Nitre in a Retort with a long Neck, or Spirit of Tartar prepar'd by Fermentation with Tartar, and its proper _Alkali_: This last is the best of all, and the use thereof ought to be continu'd. The volatile Salt of Human Bones is also very efficacious; but it is necessary to begin first with the taking of Laxative and Sudorifick Medicines, appropriated according to the respective Circumstances. The Spirit of Earth-Worms may be also apply'd outwardly, which is made by Fermentation, and may be often laid on the Part either alone, or with the Spirit of _Sal Ammoniack_. If a dislocated Bone be not set in good time, a _Coagulum_ or kind of curdled Substance is form'd in the Cavity, which hinders the reducing of it to its place; but this _Coagulum_ may be dissolv'd with the following Medicament, before you attempt to set the Bone. Take one {187} part of the destill'd Oil of Human Bones, two parts of foetid Oil of Tartar; mingle the whole, and add quick Lime to be destill'd in a Retort: Let the Parts be fomented with this Oil. If the Dislocation happen'd by the Relaxation of the Ligaments, recourse may be had to universal Sudorificks taken inwardly; as also to such Medicines as are full of an unctuous and volatile Salt, particularly Aromatick Oils, and Spirit of _Sal Ammoniack_. In the mean while Aromaticks, Resolutives, and moderate Astringents may be apply'd outwardly. * * * * * CHAP. II. _Of the Fractures of Bones._ _What is the Fracture of a Bone?_ It is the Division of the Continuity of its Parts. _After how many different manners may a Bone be broken?_ Three several ways, _viz._ cross-wise, side-wise, in its length, and perhaps in Shatters or Splinters. _By what means may a Bone be fractured?_ It may happen to be done by three sorts of Instruments, _viz._ such as are fit for bruising, cutting, or wresting; that is to say, a Bone may be divided in the Continuity of its proper Parts, by Contusion, Incision, or Contorsion. _How is the Fracture of a Bone discover'd?_ {188} Divers ways, _viz._ by the ill Disposition of the Part, which becomes shorter; by its want of Motion; by its flexibility or pliantness elsewhere than in its Articulations; by the unevenness that may be perceiv'd in its Continuity; by the cracking which is heard; sometimes also by the shooting forth of one of its ends thro' the Flesh which it hath open'd; and lastly by a Comparison made thereof with the sound Part on the other side, as that of the Right Arm with the Left. _What kind of Fracture is most difficult to be discern'd?_ It is that which happens in the length of the Bone, commonly call'd a Cleft or Fissure, which gives occasion to very great Symptoms when it is unknown: But it may be found out by the Pain and Swelling felt at the bottom of the Cleft in touching it; besides the Conjectures which may be made from the Relation of the Person who hath had a Fall, and might have heard the cracking of the Bone. _What sort of Fracture is most difficult to be cur'd?_ The shattering or splitting of a Bone in Pieces, by reason of the great Number of Splints which daily cause new Pains and Suppurations. _What is a simple and what is a complicated Fracture?_ The simple Fracture is that whereby the Bone is broken, without any other Accident; and the complicated Fracture is that which is follow'd by some Accident; as that in which there is a splitting of the Bone in pieces, or {189} where the Bone is broken in two several places, or else when the Fracture is accompany'd with a Luxation, a Wound, an Inflammation, or other Circumstances of the like Nature. _Are old Men or Children most subject to these Fractures of the Bones?_ Old Men, because their Bones are drier; whereas those of Infants are almost Cartilaginous, and yield or give way to the violence offer'd to 'em; from whence proceed the sinkings and hollowness that happen in their Skulls, especially in the Mould of their Heads, or elsewhere; for which a Remedy is found out by the means of Plaisters, Splints, and Bandages, fitted to the shape of the Parts. It is also on the same Account that Bones are more easily broken in the Winter than in the Summer. _In what Parts are the Fractures of Bones most dangerous?_ They are those that happen in the Skull and Joints; in the former by reason of the Brain; and in the latter in regard of the Nervous Parts. _What Course is to be taken by a Surgeon who is sent for to cure a Fracture?_ He ought to do three things, that is to say, at first he must incessantly endeavour to reduce it, to the end that Nature may re-unite the Parts with greater Facility, and that its Extremities may be brought together again with less trouble, before a Swelling, Inflammation, or Gangrene happen in the Part. Afterward he is to use means to retain the Parts in their proper Figure, and {190} natural Situation, and to prevent all sorts of Accidents. _How is the setting of a broken Bone to be perform'd?_ When the Fracture is Cross-wise, it must be reduc'd by Extension and contra-Extension; and when it is in length, the Coaptation or bringing together again of the Sides, is only necessary. _What is to be done in a Fracture complicated with a Wound?_ The Operator must first reduce it, and then administer the other Helps, as in a simple Fracture. _How may it be known that the reducing of the Fracture is well perform'd?_ When the Pain ceaseth; when the Part hath resum'd its natural Shape; when no Unevenness is any longer perceiv'd therein; and when it is conformable to the sound Part on the other side. _What are the Signs which shew that the Splints remain in the Fracture after it hath been reduc'd?_ They are the secret and continual Workings of the Fibres, or twitchings, that are felt by Intervals in the Part, with great Pains, which are the Indications of an Abcess arising therein; and when a Wound is join'd to the Fracture, the Lips of it are puff'd up, and become more soft and pale, the purulent Matter abounding also more than ordinary. _When the Splints appear, must they be drawn out by force?_ {191} By no means; for great care ought to be taken to avoid all manner of violent Operations; it being requisite to wait for their going out with the purulent Matter; or at most to facilitate their Passage by the use of Injections of the Tincture of Myrrh and Aloes; by the application of _Emplastrum Andreæ Crucii_, and by the help of the _Forceps_. _How is a simple Fracture to be dress'd, after it hath been reduc'd?_ The Parts are to be strengthen'd and consolidated with Liniments of _Oleum Lumbricorum_, or of Oil of St. _John_'s-Wort mingled with Wine, Brandy, or _Aqua-Vitæ;_ with Fomentations of Red Roses, Rosemary, and St. _John_'s-Wort boil'd in Wine; and with _Emplastrum contra Rupturam_, or _de Betonica_, carefully wrapping up the broken Member, but after such a manner that the two Extremities may not cross one another; and that a small Space may remain open between both. Afterward the Splints and Bands are to be apply'd, taking care to avoid binding 'em too hard, and to take 'em off every three Days, in order to refit 'em, to abate troublesome Itchings, and to give Air to the Part; by these means preventing the Gangrene, which might happen by the Suffocation of the natural Heat. If the Thighs or Legs are broken, Scarves are to be us'd to support and stay 'em in the Bed. _What space of time may there be allow'd for curing the Fracture of a Bone?_ The Cure will take up more or less time, according to the variety of the Parts, or the different thickness of the Bones: Thus to form {192} the _Callus_ of the broken Jaw-Bone, twenty Days may well be allotted; for that of the Clavicle, or that of the Shoulder-Bone, twenty four; for that of the Bones of the Elbow, thirty; for that of the Arm-Bone, forty; for that of the Wrist-Bone, and those of the Fingers, twenty; for that of the Ribs, twenty; for that of the Thigh-Bone, fifty; for that of the Leg-Bone, forty; for that of the Bones of the _Tarsus_ and Toes, twenty. _What ought to be done in particular to promote the formation of the _Callus_?_ The fractur'd Part must be rubb'd with _Oleum Lumbricorum_ and Spirit of Wine heated and mingled together: The Decoctions of Agrimony, Sayine, and Saxifrage are also to be us'd, and the _Lapis Osteocolla_ is a Specifick: It is usually given in great Comphrey-Water, or in a Decoction of Perewinkle made with Wine, and is often re-iterated. * * * * * CHAP. III. _Of the particular Fractures of the Skull._ _What is a Fracture of the_ Cranium _or Skull?_ It is a Wound of the Head complicated with a Fracture of the Skull-Bone. _After how many manners may the Skull be fractur'd?_ {193} Three several ways, _viz._ by Contusion, by Incision, and by Puncture. _What is the most dangerous of these Fractures?_ It is that which happens by Contusion; because the Concussion and Commotion is greater. _Do all the Fractures of the Skull require the use of the Trepan?_ No, the Fractures must be deep which stand in need of the help of such an Instrument; for those that are superficial may be cur'd by a simple Exfoliation. _What is that deep Fracture, wherein the use of the Trepan is absolutely necessary?_ It is that which is made in the two Tables of the Skull, penetrating to the _Meninges_ of the Brain; upon which at that time the Blood is diffus'd, and must be taken away by the Operation of the Trepan. _How may it be discover'd that the two Tables of the Skull are broken?_ By the Eyes, and by Ratiocination. _Are not the Eyes sufficient alone, and are they not more certain than Ratiocination?_ Yes; but forasmuch as things are not always seen, there is often a necessity of making use of rational Deductions to find out that which the Eyes cannot discern. _When doth it happen that the Eyes alone discover the Fracture?_ When the Wound is large and wide, so that it may be immediately view'd. _When doth it happen that Ratiocination supplies the defect of the Eyes?_ {194} When the Wound is so small that the Bone cannot be seen, and nothing appears but the Accidents. _What are the Accidents or Signs of the Fracture of the Skull?_ They are a dimmness of the Sight, and loss of the Understanding, which happen at the very Moment when the Fall or Blow is receiv'd; with the Phlegmatick Vomittings that follow soon after: These Signs are call'd _Univocal_. And there are others that bear the Name of _Equivocal_, and which confirm the former; as a Flux of Blood thro' the Nose, Eyes, and Ears, redness of the Eyes, heaviness of the Head, and puffing up of the Face; as also afterward Drowsiness, Shivering of the whole Body, Fever, _Deliriums_, Convulsions, _&c._ _Must all these Signs appear before a Determination can be made of the necessity of using the Trepan?_ No, it is sufficient to have the Univocal Signs to make a Crucial Incision in the place of the Wound, and to lay bare the Bone, in order to observe the Fracture, which sometimes is so fine, that the Operator is oblig'd to make use of Ink, which insinuates it self into the Cleft, and of a particular Instrument, with which the black Line that hath penetrated to the bottom, cannot be rubb'd out; whereas it may be easily defac'd when the Fracture is only superficial. _How long time is commonly spent before the appearing of the Accidents?_ In the Summer Season they appear in three or four Days, and at the latest in seven; in Winter {195} they are slower, and sometimes do not happen till the fourteenth Day: But at the end of this term, it may be affirm'd that the Trepan is often unprofitable. _What is requisite to be done in a doubtful Occasion; Must the Trepan be apply'd or omitted?_ The Surgeon is to have recourse to his own conscientious Discretion, which ought to serve as a Guide, and requires that we should always act according to the known Rules of Art; insomuch that after having well consider'd the Accidents, with all the Circumstances of the Wound, if there be no good grounds for the undertaking of the Operation, it is expedient to desist, and in this case to have deference to the Advice of other able Surgeons of the same Society, rather than to rely too much upon his own Judgment, to the end that he may be always secure from all manner of Blame. _Is the Trepan apply'd upon the Fracture?_ No; but on one side of it, and always in a firm place. _What Course is to be taken when a Fracture is found in a Suture?_ A double Trepan is to be made, and apply'd on each side of the Suture, by reason of the overflowing of the Blood, which may happen therein. _What Method ought to be observ'd in the curing of the Wounds of the Head, and Fractures of the Skull?_ In simple Wounds of the Head, it is necessary only to make use of Balsams, and to lay over 'em _Emplastrum de Betonica_. When there is a Contusion either in the {196} _Pericranium_, or in the Skull, the Wound must be kept open till after the Suppuration or Exfoliation. When there is only a Bunch without any Wound or Accident, it must speedily be dissolv'd with Plaister or Mortar, Chimney-Soot, Oil of Olives, and Wine, laid upon the Part between two Linnen-Rags; or else with Soot, Spirit of Wine, and Oil of St. _John_'s-Wort, wherein the Bolsters are soakt, to be in like manner apply'd with a Band. Wounds of the Head accompany'd with a Fracture, absolutely require the application of the Trepan, wherein it is requisite to make use of Oil of Turpentine to be dropt upon the Membrane of the Brain; or else Spirit of Wine mingled with Oil of Almonds, and not with the Oil or Syrrup of Roses; and to endeavour to cause a plentiful outward Suppuration. Besides, it must not be neglected to enjoyn the wounded Person to be let Blood both before and after the Operation, if he hath a Fever or a Plethory; and more especially it is to be remember'd to cause his Body to be kept open at least every other Day, with Clysters, obliging him to keep a good Diet, and to avoid all violent Agitations both of Body and Mind, abstaining from eating Flesh till the Fourteenth Day. All manner of Venery and Conjugal Embraces, which prove fatal at this time, are to be prohibited during forty Days, to be counted from the Day of the Operation; as they are also in all other considerable Wounds. * * * * * {197} CHAP. IV. _Of the _Caries_ or Ulcer of the Bones, _Exostosis_, and _Nodus_._ _What is_ Caries? It is the Putrifaction of the Substance of the Bone, or else its Ulcer or Gangrene. _Whence doth the _Caries_ of the Bone derive its Original?_ It proceeds from an internal and external Cause; the former being that which hath been produc'd at first in the Substance of the Bone; and the other that which takes its Rise from an inveterate Ulcer in the Flesh, which hath communicated its Malignity to the Substance of the Bone, and by that means corrupted it. _How is the _Caries_ known which proceeds from an inward Cause?_ By the continual and violent Pains which are felt before, and continue for a long time without diminution; as also afterward by the alteration of the Flesh that covers the Bone, and which becomes soft, spongy, and livid. _By what means is a _Caries_ that derives its Origine from an outward Cause, discover'd?_ By the quality of the purulent Matter that issueth out of the Ulcer in the Flesh, which is blackish, Unctuous, and extremely stinking; as also by the help of the Probe, that discovereth {198} asperity or roughness in the Bone when it is laid bare. _What Means are to be us'd in order to cure a _Caries_ proceeding from an external Cause?_ The Powder of Flower-de-luce may be us'd, and it is sufficient for that purpose, when the _Caries_ is superficial; but it is necessary to take _Oleum Guyaci_, and to soak Bolsters therein, to be laid upon the Ulcer when it is deep; or else _Aqua-Vitæ_ or Brandy, in which have been infus'd the Roots of Flower-de-luce, Cinnamon, and Cloves. Lastly, the actual Cautery, which is Fire, must be apply'd thereto. _What is to be done when the _Caries_ proceeds from an internal Cause?_ The Flesh must be open'd to give Passage to the _Sanies_ that runs out of the ulcerated Bone, to the end that Exfoliation may be procur'd; and if the Ulcer hath not as yet laid open the Bone on the outside, the Trepan ought to be apply'd; but the Ulcer or _Caries_ must be afterward handled, as we have even now declar'd. _What is _Exostosis_?_ It is the Swelling of a Bone made by the settling of a corrupt Humour in its proper Substance. _What is _Nodus_?_ It is a kind of gummy and wavering Tumour, which is form'd by the settling of a gross Humour between the Bone and the _Periosteum_. _Are _Exostoses_ and _Nodus_'s suppurable Tumours?_ Yes, because they sometimes produce Ulcers and Gangrenes in the Bone, which are call'd {199} _Caries_, proceeding from an internal Cause; nevertheless they are generally dissolv'd by Frictions with _Unguentum Griseum_, or by the application of Plaisters of Tobacco, or _Emplastrum de Vigo quadruplicato Mercurio_; taking also to the same purpose internal Diaphoretick and Sudorifick Medicines, with convenient Purgatives. * * * * * CHAP. V. _Of Cauteries, Vesicatories, Setons, Cupping-Glasses, and Leeches._ _What is a Vesicatory?_ The Name of Vesicatory may be attributed to every thing that is capable of raising Bladders or Blisters in the Skin; nevertheless in Surgery, by a Vesicatory is understood a Medicament prepar'd with _Cantharides_ or _Spanish_ Flies dried, which are beaten to Powder, and mingled with Turpentine, Plaisters, Leaven, and other Ingredients. _In what places, and after what manner are Vesicatories usually apply'd?_ They are apply'd every where, accordingly as there is occasion to draw out or discharge some Humour from a Part: In Defluxions of Rheum upon the Eyes or Teeth, they are laid on the Neck and Temples; in Apoplexies, behind the Ears; and so of the rest, observing always to make Frictions on the places where the {200} Application is to be made, to the end that the Vesicatory may sooner take effect. _How long time must the Vesicatory continue on the Part?_ The Blisters are generally rais'd by 'em within the space of five or six Hours; yet this Operation depends more or less upon the fineness of the Skin; and when the Bladders or Blisters appear, it is requisite to deferr the openning of 'em for some time, to the end that Nature may have an Opportunity to introduce a new Scarf-Skin, by which means the Pain may be avoided that would be felt, if the Skin were too much expos'd to the Air. _What is a Cautery?_ It is a Composition made of many Ingredients, which corrode, burn, and make an Escar on the Part to which they are apply'd. _How many sorts of Cauteries are there in general?_ There are two kinds, _viz._ the Actual and the Potential; the former are those that have an immediate Operation; as Fire, or a red-hot Iron; and the others are those that produce the same Effect, but in a longer space of time; such are the ordinary Cauteries compos'd of Caustick Medicaments. _Which are the most safe, the Actual or the Potential Cauteries?_ A distinction is to be made herein; for Actual Cauteries are safest in the Operation, because they may be apply'd wheresoever one shall think fit, as also for as long a time, or for any purpose: Whereas the Potential cannot be {201} guided after the same manner. But in Hæmorrhages the Potential Cauteries are most eligible, by reason that the Escar produc'd by 'em not being so speedily form'd, the Vessels are better clos'd, and they are not so subject to open again when it falls off; as it often happens in the Fall of an Escar made by Fire. _In what places are Cauteries usually apply'd?_ In all places where an Attraction is to be made, or an Intemperature to be corrected, or a Flux of Humours to be stopt, by inducing an Escar on the Part: However they are commonly laid upon the Nape of the Neck, between the first and second _Vertebra_; on the outward Part of the Arm in a small Hole between the Muscle _Deltoides_ and the _Biceps_; above the Thigh, between the Muscle _Sartor_, and the _Vastus Internus_; and on the inside of the Knee, below the Flexors of the Leg; observing every where that the Cautery be plac'd near the great Vessels, to the end that it may draw out and cleanse more abundantly. _What is the Composition of the Potential Cauteries?_ They may be made with quick Lime, Soap, and Chimney-Soot; or else take an Ounce of _Sal Ammoniack_, two Ounces of burnt _Roman_ Vitriol, three Ounces of quick Lime, and as many of calcin'd Tartar; mingle the whole Mass together in a _Lixivium_ of Bean-Cod Ashes, and cause it to evaporate gently to a Consistence: Let this Paste be kept for use in a dry place, and in a well-stopt Vessel. Or else the Silver-Cautery, or _Lapis Infernalis_ may be prepar'd after the following manner: {202} Take what quantity you please of Silver, let it be dissolv'd with thrice as much Spirit of Nitre in a Vial, and set the Vial upon the Sand-Fire, to the end that two third parts of its Moisture may evaporate: Then pour the rest scalding-hot into a good Crucible, plac'd over a gentle Fire, and the Ebullition being made, the heat of the Fire must be augmented, till the Matter sink to the bottom, which will become as it were an Oil: Afterward pour it into a somewhat thick and hot Mould, and it will coagulate, so as to be fit for Use, if it be kept in a well-stopt Vial. This Cautery is the best; and an Ounce of Silver will yield one Ounce and five Drams of _Lapis Infernalis_. _What is a Seton?_ It is a String of Silk, Thread, or Cotton, threaded thro' a kind of Pack-Needle, with which the Skin of a Part is to be pierc'd thro', to make an Ulcer therein, that hath almost the same effect as a Cautery. _What is most remarkable in the Application of a Seton?_ It ought to be observ'd, that the String must be dipt in Oil of Roses, and that one end of it must always be kept longer than the other, to facilitate the running of the Humours. _In what Parts is the Seton to be apply'd?_ The Nape of the Neck is the usual place of its Application, altho' it may be made in any part of the Body where it is necessary. It sometimes happens that a Surgeon is oblig'd to use a kind of Seton in such Wounds made with a Sword, or by Gun-shot, as pass quite {203} thro' from one side to the other; then the String or Skain must be dipt in convenient Ointments or Medicinal Compositions; and as often as the Dressings are taken away, it will be requisite to cut off the Part soakt in the Purulent Matter, which must be taken out of the Ulcer. _What is a Cupping-Glass?_ It is a Vessel or kind of Vial, made with Glass, the bottom whereof is somewhat broader than the top, which is apply'd to the Skin to cause an Attraction. There are two sorts of these Cupping-Glasses, _viz_, the Dry, and the Wet; the former are those that are laid upon the Skin without opening it; and the latter those that are apply'd with Scarification. _In what Diseases are Cupping-Glasses us'd?_ In all kinds where it is necessary to make any Attraction; but more especially in Apoplexies, Vapours in Women, Palsies, and other Distempers of the like Nature. But the Applications of Cupping-Glasses are altogether different; for in Apoplexes they are generally set upon the Shoulders or upon the _Coccyx_; in Vapours upon the inside of the Thighs; and in Palsies upon the Paralytick Part it self. _What is a Leech?_ It is an Animal like a little Worm which sucks the Blood, and is commonly apply'd to Children and weak Persons, to serve instead of Phlebotomy: Leeches are also us'd for the discharging of a Defluxion of Humours in any Part; as also in the Hæmorrhoidal Veins when they are too full; in the _Varices_ and in several parts of the Face. {204} _What choice ought to be made of Leeches?_ It is requisite to take those that have their Backs greenish, and their Bellies red; as also to seek for 'em in a clear running Stream, and to cast away those that are black and hairy. * * * * * CHAP. VI. _Of Phlebotomy._ _What is Phlebotomy?_ It is an evacuation of Blood procur'd by the artificial Incision of a Vein or Artery, with a design to restore Health. _Which are the Vessels that are open'd in Phlebotomy or Blood-letting?_ They are in general all the Veins and Arteries of the Body, nevertheless some of 'em are more especially appropriated to this Operation; as the _Vena Præparata_ in the Forehead; the _Ranulæ_ under the Tongue; the Jugular Veins and Arteries in the Neck; the Temporal Arteries in the Temples; the _Cephalick_, _Median_, and _Basilick_ Veins in the inside of the Elbow; the _Salvatella_ between the Ring-Finger and the Little-Finger; the _Poplitæa_ in the Ham; the _Saphena_ in the internal _Malleolus_ or Ankle; and the _Ischiatica_ in the external. _What are the Conditions requisite in the due performing of the Operation of Phlebotomy?_ They are these, _viz._ to make choice of a proper Vessel; not to open any at all Adventures; not to let Blood without necessity, nor {205} without the Advice of a Physician; whose Office it is to determine the Seasons or Times convenient for that purpose; as that of Intermission in an Intermitting Fever; that of Cooling in the Summer; and that of Noon-tide in the Winter; and lastly, to take away different quantities of Blood; for in the Heat of Summer they ought to be lesser, and greater in the Winter. _What are the Accidents of Phlebotomy?_ They are an Impostume, a _Rhombus_, an _Echymosis_, an _Aneurism_, Lipothymy, Swooning, and a Convulsion. _What is a _Rhombus_?_ It is a small Tumour of the Blood which happens in the place where the Operation is perform'd either by making the Orifice too small, or larger than the Capaciousness of the Vessel will admit. The _Rhombus_ is cur'd by laying upon it a Bolster dipt in fair Water, between the Folds of which must be put a little Salt, to dissolve and prevent the Suppuration. _How may it be perceiv'd that an Artery hath been prickt or open'd in letting Blood?_ The Puncture of an Artery produceth an Aneurism; and the Opening of it causeth a Flux of Vermilion Colour'd Blood, which issueth forth in abundance, and by Leaps. _Are the Leaps which the Blood makes in running, a certain Sign that it comes from an Artery?_ No, because it may so happen, that the _Basilick_ Vein lies directly upon an Artery, the beating of which may cause the Blood of the {206} _Basilica_ to run out leaping: Therefore these three Circumstances ought to be consider'd jointly, that is to say, the Vermilion Colour, the great quantity and the Leaps, in order to be assur'd that the Blood proceeds from an Artery. _How may it be discover'd that a Tendon hath been hurt in letting Blood?_ It is known when in opening the _Median_ Vein, the end of the Lancet hath met with some Resistance; when the Patient hath felt great Pain, and afterward when the Tendon apparently begins to be puff'd up, and the Arm to swell. A Remedy may be apply'd to this Accident thus; after having finish'd the Operation, a Bolster steep'd in _Oxycratum_ is to be laid upon the Vessel, a proper Bandage is to be made, and the Arm must be wrapt up in a Scarf: If the Inflammation that ariseth in the Part be follow'd with Suppuration, it must be dress'd with a small Tent; and if the Suppuration be considerable, it is necessary to dilate the Wound, and to make use of Oil of Eggs and Brandy, or _Arcæus_'s Liniment, with a good Digestive; as also to apply _Emplastrum Ceratum_; to make an Embrocation on the Arm with Oil of Roses; and to dip the Bolsters in _Oxycratum_ to cover the whole Part. _Is it not to be fear'd that some Nerve may be wounded in letting Blood?_ No, they lie so deep that they cannot be touch'd. _Under what Vein is the Artery of the Arm?_ It is usually situated under the _Basilica_. {207} _What Course is proper to be taken to avoid the Puncture of an Artery in letting Blood?_ It must be felt with the Hand before the Ligature is made, observing well whether it be deep or superficial; for when it lies deep, there is nothing to be fear'd; and when it is superficial, it may be easily avoided by pricking the Vein either higher or lower. _What is to be done when an Artery is open'd?_ If it be well open'd, it is requisite to let the Blood run out till the Person falls into a _Syncope_ or Swoon, by which means the Aneurism is prevented; and afterward the Blood will be more easily stopt: It remains only to make a good Bandage with many Bolsters, in the first of which is simply put a Counter or a Piece of Money; but a bit of Paper chew'd will serve much better, with Bolsters laid upon it in several Folds. _If the Arteries cause so much trouble when open'd accidentally, why are those of the Temples sometimes open'd on purpose, to asswage violent Pains in the Head?_ By reason that in this place the Arteries are situated upon the Bones that press 'em behind; which very much facilitates their re-union. _Are not the Arteries of Persons advanc'd in Years more difficult to be clos'd than those of Children?_ Yes. {208} _Are there not Accidents to be fear'd in letting Blood in the Foot?_ Much less than in the Arm; because the Veins of the _Malleoli_ or Ankles are not accompany'd either with Arteries or Tendons; which gave occasion to the Saying, _That the Arm must be given to be let Blood only to an able Surgeon, but the Foot may be afforded to a young Practitioner_. * * * * * {209} A TREATISE OF _Chirurgical Operations_. * * * * * CHAP. I. _Of the Operation of the Trepan._ This Operation is to be perform'd, when it is inferr'd from the Signs of which we have already given a particular Account, that some Matter is diffus'd over the _Dura Mater_. The Trepan must not be us'd in the _Sinus Superciliares_, by reason of their Cavity; nor in the Sutures, in regard of the Vessels that pass thro' 'em; nor in the Temporal Bone without great necessity, especially in that part of it which is join'd to the Parietal-Bone, lest the end of this Bone shou'd fly out of its place, since it is only laid upon the Parietal; nor in the middle of the Coronal and Occipital-Bones, by reason of an inner {210} Prominence wherein they adhere to the _Dura Mater_; nor in the Passage of the Lateral _Sinus's_ that are situated on the side of the Occipital. If the Fissure be very small, the Trepan may be apply'd upon it, altho' it is more expedient to use this Instrument on the side of the Fissure in the lower part; neither is the Trepan to be set upon the Sinkings; and if the Bones are loosen'd or separated, there needs no other trepanning than to take 'em away with the Elevatory. The Operation must be begun with Incision, which is usually made in form of a Cross, if the Wound be remote from the Sutures, and there are no Muscles to be cut, and in the shape of the Letter T. or of the Figure 7. if it be near the Sutures, so that the Foot of the 7. or of the T. ought to be parallel to the Suture, the top of the Letter descending toward the Temples; it is also made in the middle of the Forehead. If it be sufficient to make a longitudinal Incision in the Forehead; its Wrinkles may be follow'd, and there will be less Deformity in the Scar; but it is never done Crosswise in this Part, and the Lips of the Wound are not to be cut. If an Incision be made on the Muscle _Crotaphites_, and on those of the back-part of the Head, it may be done in form of the Letter V. the Point of which will stand at the bottom of the Muscles; nevertheless it is more convenient to make a longitudinal Incision, by which means fewer Fibres will be cut; and it is always requisite to begin at the lower part, to avoid being hindred by the Hæmorrhage. {211} The Incisions are to be made with the Incision-Knife, and that too boldly when there are no Sinkings; but if there be any, too much weight must not be laid upon 'em: Thus the Incision being finish'd, the Lips of the Skull are to be separated either with the Fingers, or some convenient Instrument; Then if there be no urgent Occasion to apply the Trepan, it may be deferr'd till the next Day, the Wound being dress'd in the mean time with Plaisters, Bolsters, Pledgets, and a large Kerchief or upper Dressing, the use of which we shall shew hereafter. The Operation is begun with the Perforative, to make a little Hole for the fixing of the Pyramid or Pin which is in the Round; afterward the Round is to be apply'd, holding the Handle of the Trepan with the Left-hand, and turning with the other very fast in the beginning; but when the Round hath made its way, it is lifted up to remove the Pin, lest this Point shou'd hurt the _Dura Mater_: Thus the Round being taken off from time to time, to be cleans'd from the Filings that stick thereto, is set on again, and the Operator begins his Work of turning anew, which must be carry'd on gently when any Blood appears, to the end that the first Table of the piece of Bone which is remov'd may not fly from the second: When it comes near the _Dura Mater_, the Operator must proceed, in like manner, gently, searching with a Feather round about the Bone, to observe whether he still continueth his Course in the Skull. He must also often lift up the Trepan to search the Hole, to cleanse the Instrument, and to keep {212} it from growing hot. As often as the Trepan is taken off, let him search with a Feather, to see whether the Bone be cut equally; and if it be not, he must lean more on that side which is least cut. If it be necessary to make use of the _Terebella_, the Hole must be made in the beginning, whilst the Bone is as yet firm; and when the Piece begins to move, the _Terebella_ is to be put very gently into its Hole, without pressing the Bone, to draw it out; or else it may be taken away with the Myrtle-Leaf, which is an Instrument made of a firm Silver-Plate somewhat crooked. When the Piece is thus remov'd, the uneven Parts that remain at the bottom of the Hole, are to be cut with the _Lenticula_; and if there be any Sinkings, they may be rais'd with the Elevatory. Whereupon the _Dura Mater_ may be compress'd a little with the _Lenticula_, to facilitate the running out of the Blood, the Wounded Person being oblig'd to stoop with his Head downward, stopping his Nose and Mouth, and holding his Breath for a while, to cause the Matter to run out: Then the _Dura Mater_ may be wip'd with Lint; but if any _Pus_ or corrupt Matter lies underneath, it must be pierc'd with a Lancet wrapt up in a Tent, that it may not be perceiv'd by the Assistants. Afterward a _Sindon_ or very fine Linnen Rag dipt in a proper Medicament, is put between the _Dura Mater_ and the Skull; the Hole is fill'd with small Bolsters steept in convenient Medicinal Liquors; and the Wound is dress'd with Pledgets, a Plaister, and a Kerchief. {213} But the Hole ought to be well stopt with Bolsters, because the _Dura Mater_ is sometimes so much inflam'd, that it bursts forth; so that if any Excrescences arise therein, and go out of the Hole, having small Roots, they may be bound and cut; but if their Roots be large, they must be press'd close with little Bolsters steept in Spirituous Medicines. Here it may not be improper to observe, that the Operation of the Trepan ought to be perform'd more gently in Children than in adult Persons, in regard that their Bones are more tender, and that Oily Medicines must not be us'd, but Spirituous. The Exfoliation is made sometimes sooner, and sometimes later; but the _Callus_ usually covers the opening of the Skull within the space of forty or fifty Days, if no ill Accident happens. In great Fractures, where there is no longer any connexion between the Bones, it is requisite to take 'em away. _Of the Bandage of the Trepan._ The proper Bandage to be us'd after the Operation of the Trepan, is the great Kerchief, which is a large Napkin folded into two parts after such a manner that the side which toucheth the Head exceeds that which doth not touch it in the breadth of four Fingers; it is apply'd to the Head in the middle, whilst a Servant holds the Dressing with his Hand: Then the two upper ends of the Napkin being brought under Chin, the Surgeon takes the two lower, and draws 'em streight by the sides, so as that side the Napkin, which is four Fingers broader {214} than the other, may be laid upon the Forehead: Afterward the two ends of the Napkin are cross'd behind the Head, and fasten'd at their Extremities with Pins, without making any Folds, that might hurt the Part; but the ends of the Napkin which fall upon the Shoulders, are rais'd up to the Head near the lesser Corner of the Eyes; and the two ends under the Chin are fasten'd with Pins, or else tied in a Knot. * * * * * CHAP. II. _Of the Operation of the _Fistula Lachrymalis_._ This Operation is perform'd when there is a Fistulous Ulcer in the great Corner of the Eye, after this manner: The Patient being plac'd in a convenient Posture, and having his sound Eye bound up, to take away the sight of the Instruments; the Operator causeth the other Eye to be kept steady with a Bolster held with an Instrument, and makes an Incision with a Lancet in form of a Crescent upon the Tumour, taking care to avoid cutting the Eye-Lid and the little Cartilage which serves as a Pulley to the great Oblique Muscle. If the Bone be putrify'd with a _Caries_, an Actual Cautery may be apply'd thereto, using for that purpose a small Funnel or Tube, thro' the Canal of which the Cautery is convey'd to the Bone. {215} But the Bone must not be pierc'd, for it is exfoliated entire by reason of its smallness; and so the Hole is made without any Perforation. _The Dressing and Bandage of the _Fistula Lachrymalis_._ The Wound is fill'd with small dry Pledgets, and cover'd with a Plaister and Bolster: The Bandage is made with an Handkerchief folded triangular-wise, the ends of which are fasten'd behind the Head. If the Flesh grows too fast, it may be consum'd with the _Lapis Infernalis_; and if there be occasion to dilate the Wound, to facilitate the Exfoliation, it may be done with little pieces of Spunge prepar'd, and put into it. Afterward Causticks are to be us'd, to eat away the Callous Parts, which may be mingled with Oily Medicines, to weaken their Action, taking care, nevertheless, that the Eye receive no dammage by 'em. If the Bone be corrupted, a little _Euphorbium_ may be apply'd; or else the small Pledgets steept in the Tincture of Myrrh and Aloes; then the Ulcer may be handled as all others. * * * * * {216} CHAP. III. _Of the Operation of the _Cataract_._ This Operation is perform'd when there is a small Body before the Apple of the Eye, which hinders the Sight from entring into it; but it is undertaken only in Blew, Green, and Pearl-colour'd Cataracts, or in those that are of the Colour of polish'd Steel; and not in Yellow, Black, or Lead-colour'd. To know whether the Cataract be fit to be couch'd, the Patient's Eye must be rubb'd; so that if the Cataract remains unmoveable, it is mature enough; but if it changeth its place, it is requisite to wait till it become more solid. The Spring and Autumn are the most proper Seasons for performing the Operation. To this purpose the Patient being set down with his Eyes turn'd toward the Light, and having his sound Eye bound up, the Surgeon must likewise sit on a higher Seat, whilst the Patient's Head is held by a Servant; and his Eye being turn'd toward his Nose, is kept steady with a _Speculum Oculi_, which is a little Iron-Instrument made like a Spoon, pierc'd in the middle, so that the Ball of the Eye may be let thro' this Hole: Then the Surgeon taking a Steel-Needle either round or flat, accordingly as he shall judge convenient, perforates the Conjunctive at the end of the Corneous Tunicle, on the side of the little Corner of the {217} Eye, and boldly thrusts his Needle into the middle of the Cataract, which he at first pusheth upward, to loosen it with the Point of the Needle; and then downward, holding it for some time with his Needle below the Apple of the Eye. If it ascend again after it is let go, it must be depress'd a second time; but the Operation is finish'd when it remains in the same place whereto it was thrust; neither is the Needle to be remov'd till this be done, and the Cataract entirely couch'd. In taking out the Needle, the Eye-Lid must be pull'd down, and press'd a little over the Eye. _The Dressing and Bandage,_ Is to cause both the Patient's Eyes to be clos'd and bound up; then he must be oblig'd to keep his Bed during seven or eight Days, and some Defensative is to be laid upon the sore Eye, to hinder the Inflammation. M. _Dupré_, Surgeon to the Hospital of _Hôtel-Dieu_ at _Paris_, a Person well vers'd in these kinds of Operations, hath observ'd, that after the same manner as Cataracts were form'd in a very little space of time in perfect Maturity; it happen'd also very often, that the Cataracts which were suppos'd to have got up again, were not the very same with those that were couch'd, but rather a new _Pellicula_ or little Skin, which sometimes hath its Origine in the top of the _Uveous_ Tunicle, and is caus'd only by a very considerable Relaxation of the Excretory Vessels from the Sources of the Aqueous Humour which in filtrating permits the running {218} of many heterogeneous Parts, the Encrease of which produceth a new Cataract. _Of other Operations in the Eyes._ Sometimes a sort of purulent Matter is gather'd together under the Corneous Tunicle; so that to draw it out, the Eye must be fixt in a Posture with the _Speculum Oculi_, and after a small Incision made therein with a fine Lancet, is to be press'd a little, to let out the Matter; but if it be too thick, it may be drawn forth by sucking gently with a small Tube or Pipe, having a little Vial in the middle, into which the Matter will fall as it is suck'd out. Sometimes a small Tumour ariseth in the Eye, which being ty'd at its Root with a Slip-Knot, to streighten it from time to time, will at length be dissolv'd: But if the Tumour lie in the Hole of the Apple of the Eye, this Operation must not be admitted, lest the Scar shou'd hinder the Passage of the Light. Sometimes also a somewhat hard Membrane, call'd _Unguis_, appears in the great corner of the eye, which when it sticks thereto, may be cut off by binding it; this is done with a Needle and Thread, which is pass'd thro' the Membrane, and afterward ty'd. If the Eye-Lids are glu'd together, a crooked Needle without a Point may be threaded, and pass'd underneath 'em; then the ends of the Thread may be drawn, to lift up the Eye-Lids, and they may be separated with a Lancet. {219} If the Hairs of the Eye-Lids or Eye-Brows offend the Eye, they must be pull'd out with a Pair of Tweezers or Nippers; and when any small, hard, and transparent Tumours arise in the Eye-Lids, they are to be open'd, to let out the corrupt Matter. * * * * * CHAP. IV. _Of the Operation of the _Polypus_._ This Operation is necessary, when there are any Excrescences of Flesh in the Nostrils, which, nevertheless, when they are livid, stinking, hard, painful, and sticking very close, must not be tamper'd with, because they are Cancers. But if they are whitish, red, hanging, and free from Pain, the Cure may be undertaken after this manner: Take hold of the _Polypus_ with a Pair of _Forceps_, as near its Root as is possible, and turn 'em first on one side, and then on another, till it be pull'd off. If the _Polypus_ descends into the Throat, it may be drawn thro' the Mouth with crooked _Forceps_; and if an Hæmorrhage shou'd happen after the Operation, it may be stopt by thrusting up into the Nostrils certain Tents soakt in some Styptick Liquor; or else by Syringing with the same Liquor. * * * * * {220} CHAP. V. _Of the Operation of the _Hare-Lip_._ This Operation is perform'd when the Upper-Lip is cleft; but if there be a great loss of Substance, it must not be undertaken; neither ought it to be practis'd upon old nor scorbutick Persons, nor upon young Children, by reason that their continual Crying wou'd hinder the re-union. But if any are desirous that it shou'd be done to these last, they are to be kept from taking any rest for a long time, to the end that they may fall a-sleep after the Operation, which is thus effected: If the Lip sticks to the Gums, it is to be separated with an Incision-Knife, without hurting 'em; then the Hare-Lip must be cut a little about the edges with Sizzers, that it may more easily re-unite, the edges being held for that purpose with a Pair of Pincers, whilst the Servant who supports the Patient's Head, presseth his Cheeks before, to draw together the sides of the Hare-Lip: Whereupon the Operator passeth a Needle with wax'd Thread, into the two sides of the Wound, from the outside to the inside at a Thread's distance from each. But care must be had that the two Lips of the Hare-Lip be well adjusted, and very even; the Thread being twisted round the Needle by crossing it above. {221} _The Dressing and Bandage._ After the Lips are wash'd with warm Wine, the Points of the Needles must be cut off, small Bolsters being laid under their ends; then the Wound is to be dress'd with a little Pledget cover'd with some proper Balsam, putting at the same time under the Gum a Linnen Rag steep'd in some desiccative Liquor, lest the Lip shou'd stick to the Gum, if it be necessary to keep 'em a-part. Lastly, upon the whole is to be laid an agglutinative Plaister, supported with the uniting Bandage, which is a small Band perforated in the middle; it is laid behind the Head, and afterward drawn forward, one of its ends being let into the Hole which lies upon the Sore: Then the two ends of the Band are turn'd behind the Head upon the same Folds where they are fasten'd, sticking therein a certain Number of Pins, proportionably to the length of the Wound. The Patient must be dress'd three Days after; and it is requisite at the first time only to untwist half the Needle, loosening the middle Thread if there be three; to which purpose a Servant is to thrust the Cheeks somewhat forward. On the eighth Day the middle Needle may be taken off, if it be a young Infant; nevertheless the Needles must not be remov'd till it appears that the sides are well join'd; neither must they be left too long, because the Holes wou'd scarce be brought to close. * * * * * {222} CHAP. VI. _Of the Operation of _Bronchotomy_._ This Operation becomes necessary, when the Inflammation that happens in the _Larynx_ hinders Respiration, and is perform'd after this manner: The Wind-Pipe is open'd between the third and fourth Ring, above the Muscle _Cricoides_, or else in the middle of the Wind-Pipe; but in separating the Muscles call'd _Sternohyodei_, care must be had to avoid cutting the recurrent Nerves, lest the Voice shou'd be lost; as also the Glandules nam'd _Thyroides_. The Space between the Rings is to be open'd with a streight Lancet, kept steady with a little Band, and a transverse Incision is to be made between 'em: Before the Lancet is taken out, a Stilet is put into the Opening, thro' which passeth a little Pipe, short, flat, and somewhat crooked at the end, which must not be thrust in too far, for fear of exciting a Cough. This Pipe hath two small Rings for the fastening of Ribbans, which are ty'd round about the Neck; and it must be left in the Wound till the Symptoms cease. Afterward it is taken away, and the Wound is dress'd, the Lips of it being drawn together again with the uniting Bandage, which hath been already describ'd. * * * * * {223} CHAP. VII. _Of the Operation of the _Uvula_._ When the _Uvula_ or Palate of the Mouth is swell'd so as to hinder Respiration or Swallowing, or else is fallen into a Gangrene, it may be extirpated thus: The Tongue being first depress'd with an Instrument call'd _Speculum Oris_, the Palate is held with a _Forceps_, or cut with a Pair of Sizzers; or else a Ligature may be made before it is cut; and the Mouth may be afterward gargl'd with Astringent Liquors. * * * * * CHAP. VIII. _Of the Operation of a Cancer in the Breast._ The Cancer at first is not so big as a Pea, being a small, hard, blackish Swelling, sometimes livid, and very troublesome by reason of its Prickings; but when it is encreas'd, the Tumour appears hard, Lead-colour'd, and livid, causing in the beginning a Pain that may be pretty well endur'd, but in the increase it grows intolerable, and the Stink is extremely noisome. When it is ready to Ulcerate, the Heat is vehement, with a pricking Pulsation; and the Veins round about are turgid, being {224} fill'd with black Blood, and extended as it were the Feet of a Crab or Crey-Fish, till Death happen. When this Tumour is not ulcerated, it is call'd an _Occult Cancer_; and an _Apparent_ one when it breaks forth into an open Ulcer. To palliate an Occult Cancer, and prevent its Ulceration, a Cataplasm or Pultis of Hemlock very fresh may be apply'd to the Part. All the kinds of Succory, the Decoction of _Solanum_ or Night-shade; the Juices of these Plants, as also those of Scabious, _Geranium_ or Stork-Bill, _Herniaria_ or Rupture-Wort, Plantain, _&c._ are very good in the beginning. River-Crabs pounded in a Leaden-Mortar, and their Juice beaten in a like Mortar, are an excellent Remedy; as also are Humane Excrements or Urine destill'd, and laid upon the Occult Cancer: Or else, Take an Ounce of calcin'd Lead, two Ounces of Oil of Roses, and six Drams of Saffron; let the whole Composition be beaten in a Mortar with a Leaden Pestle, and apply'd. The Amalgama of _Mercury_ with _Saturn_ is likewise a very efficacious Remedy. In the mean while the Patient may be purg'd with black Hellebore and _Mercurius Dulcis_, taking also inwardly from one Scruple to half a Dram of the Powder of Adders, given to drink, with half the quantity of Crab's-Eyes: But very great care must be taken to avoid the Application of Maturatives or Emollients, which wou'd certainly bring the Tumour to Ulceration. {225} When the Cancer is already ulcerated, the Spirit of Chimney-Soot may be us'd with good Success; and the Oil of Sea-Crabs pour'd scalding hot into the Ulcer, is an excellent Remedy. But if it be judg'd expedient entirely to extirpate the Cancer, it may be done thus: The sick Patient being laid in Bed, the Surgeon takes the Arm on the side of the Cancer, and lifts it upward and backward, to give more room to the Tumour; then having pass'd a Needle with a very strong Thread thro' the bottom of the Breast, he cuts the Thread to take away the Needle, and passeth the Needle again into the Breast, to cause the Threads to cross one another. Afterward these four ends of the Threads are ty'd together, to make a kind of Handle to take off the Tumour, which is cut quite round to the Ribs with a very sharp Rasor. The Cutting is usually begun in the lower Part to end in the Vessels near the Arm-Pit, where a small Piece of Flesh is left, to stop the Blood with greater Facility: Then having laid a Piece of Vitriol upon the Vessels, or Bolsters soakt in styptick Water; the sides of the Breast are to be press'd with the Hand, to let out the Blood and Humours; and an Actual Cautery is to be lightly apply'd thereto. _The Dressing._ The Wound is to be dress'd with Pledgets strew'd with Astringent Powders, a Plaister, a Bolster, a Napkin round the Brest, and a Scapulary to support the whole Bandage. {226} But instead of passing Threads cross-wise, to form a Handle, with which the Breast may be taken off, it wou'd be more expedient to make use of a sort of _Forceps_ turn'd at both ends in form of a Crescent, after such a manner that those ends may fall one upon another when the _Forceps_ are shut. Thus the Surgeon may lay hold on the Breast with these _Forceps_, and draw it off, after having cut it at one single Stroak with a very flat, crooked, and sharp Knife. Neither is it convenient to apply the Actual Cautery to stop the Hæmorrhage, because it is apt to break forth again anew, when the Escar is fall'n off, When the Tumour is not as yet ulcerated, a Crucial Incision may be made in the Skin, without penetrating into the Glandulous Bodies; then the four Pieces of the Glandules being separated, the Cancerous Tumour may be held with the _Forceps_, and afterward cut off. If there be any Vessels swell'd, they may be bound before the Tumour is taken away; but if the Tumour sticks close to the Ribs, the Operation is not usually undertaken. * * * * * {227} CHAP. IX. _Of the Operation of the _Empyema_._ This Operation is perform'd when it may be reasonably concluded that some corrupt Matter is lodg'd in the Breast, which may be perceiv'd by the weight that the Patient feels in fetching his Breath; being also sensible of the floating of the Matter when he turns himself from one side to another. If the Tumour appears on the outside, the Abcess may be open'd between the Ribs; but if no external Signs are discern'd, the Surgeon may choose a more convenient place to make the Opening. Thus when the Patient is set upon his Bed, and conveniently supported, the Opening is to be made between the second and third of the Spurious Ribs, within four Fingers breadth of the Spine, and the lower Corner of the _Omoplata_; to this purpose the Skin is to be taken up a-cross, to cut it in its length, the Surgeon holding it on one side, and the Assistant on the other. The Incision is made with a streight Knife two or three Fingers breadth long, and the Fibres of the great Dorsal-Muscle are cut a-cross, that they may not stop the Opening. Then the Surgeon puts the Fore-Finger of his Left-hand into the Incision, to remove the Fibres, and divides the Intercostal Muscles, guiding the Point of the Knife with his Finger to pierce the _Pleuron_, for fear of wounding {228} the Lungs, which sometimes adhere thereto, the Opening being thus finish'd, if the Matter runs well, it must be taken out; but if not, the Fore-Finger must be put into the Wound, to disjoyn those Parts of the Lungs that stick to the _Pleuron_. To let out the Matter, the Patient must be oblig'd to lean on one side, stopping his Mouth and Nose, and puffing up his Cheeks, as if he were to blow vehemently; then if Blood appears, a greater quantity of it may be taken away than if it were Matter, in regard that a Flux of Matter weakens more than that of Blood. It is also worth the while to observe, that in making the Incision, the Intercostal Muscles ought to be cut a-cross, that the side of the Ribs may not be laid bare, by which means the Wound will not so soon become Fistulous. If it be judg'd that purulent Matter is contain'd in both sides of the Breast, it is requisite that the Operation be done on each side; it being well known that the Breast is divided into two Parts by the _Mediastinum_: But in this case the two Holes made by the Incision must not be left open at the same time, for fear of suffocating the Patient. _The Dressing and Bandage._ The Wound is dress'd with a Tent of Lint arm'd with Balsam, being soft, and blunt at the end, which enters only between the Ribs, for fear of hurting the Lungs; but a good Pledget of Lint is more convenient than a Linnen {229} Tent, however a Thread must be ty'd to the Pledget or Tent, lest it shou'd fall into the Breast; and Bolsters are to be put into the Wound; as also a Plaister or Band over the whole. This Dressing is to be kept close with a Napkin fasten'd round the Breast with Pins, and supported by a Scapulary, which is a sort of Band, the breadth of which is equal to that of six Fingers, having a Hole in the middle to let in the Head: One of its ends falls behind and the other before; and they are both fasten'd to the Napkin. Thus the Patient is laid in Bed, and set half upright. If the Lungs hinder the running out of the Matter, a Pipe is us'd, and the Wound afterward dress'd according to Art. * * * * * CHAP. X. _Of the Operation of the _Paracentesis_ of the Lower-Belly._ This Manual Operation is sometimes necessary in a Dropsie, when Watry Humours are contain'd in the Cavity of the Belly, or else between the Teguments. The Disease is manifest by the great Swelling; and the Operation is perform'd with a Cane, or a Pipe made of Silver or Steel, with a sharp Stilet at the end; altho' the Ancients were wont to do it with a Lancet. The Patient being supported, sitting on a Bed, or in a great Elbow-Chair, to the end that the Water may run downward, {230} a Servant must press the Belly with his Hands, that the Tumour may be extended, whilst the Surgeon perforates it three or four Fingers breadth below the Navel, and makes the Puncture on the side, to avoid the White-Line; but before the Opening is made, it is expedient that the Skin be a little lifted up. The pointed Stilet being accompany'd with its Pipe, remains in the Part after the Puncture; but it is remov'd to let out the Water; and a convenient quantity of it is taken away, accordingly as the Strength of the Patient will admit. The Stilet makes so small an Opening, that it is not to be fear'd lest the Water shou'd run out, which might happen in making use of the Lancet, because there wou'd be occasion for a thicker Pipe. When a new Puncture is requisite, it must be begun beneath the former; but if the Waters cause the Navel to stand out, the Opening may be made therein, without seeking for any other place. _The Bandage and Dressing_ Are prepar'd with a large four-double Bolster kept close with a Napkin folded into three or four Folds, which is in like manner supported by the Scapulary. _The Operation of the _Paracentesis_ of the _Scrotum__ Is undertaken when those Parts are full of Water, after this manner: Assoon as the Patient is plac'd in a convenient Posture, either {231} standing or sitting, the Operator lays hold on the _Scrotum_ with one Hand, presseth it a little to render the Tumour hard, and makes a Puncture, as in the _Paracentesis_ of the _Abdomen_. In an _Hydrocele_ that happens to young Infants, the Opening may be made with a Lancet, to take away all the Water at once: But in Men, especially when there is a great quantity thereof, it is more expedient to do it with the sharp-pointed Pipe; but the Testicles are to be drawn back, for fear of wounding 'em with the Point of the Instrument. If the _Hydrocele_ be apparently _Encysted_, the Membrane containing the Water is to be consum'd with Causticks, which is done by laying a Cautery in the place where the Incision shou'd be made, and afterward opening the Escar with a Lancet. When the Puncture is made, it ought to be done in the upper-part of the _Scrotum_, because it is less painful than the lower, and less subject to Inflammation. * * * * * CHAP XI. _Of the Operation of _Gastroraphy_._ This Operation is usually perform'd when there is a Wound in the Belly so wide as to let out the Entrails. If there be a considerable Wound in the Intestine, it may be sow'd up with the Glover's Stitch, the manner of making which we have before explain'd. If {232} the _Omentum_ or Caul be mortify'd, the corrupted Part must be cut off; to which purpose it is requisite to take a Needle with waxed Thread, and to pass it into the sound Part a-cross the Caul, without pricking the Vessels. Then the Caul being ty'd on both sides with each of the Threads that have been pass'd double, may be cut an Inch below the Ligature, and the Threads will go thro' the Wound, so as to be taken away after the Suppuration. Afterward the Intestines are to be put up again into the Belly, by thrusting 'em alternately with the end of the Fingers. But if they cannot be restor'd to their proper Place without much difficulty, Spirituous Fomentations may be made with an handful of the Flowers of Camomile and Melilot, an Ounce of Anise, with as much Fennel and Cummin-Seeds; half an Ounce of Cloves and Nutmegs: Let the whole Mass be boil'd in Milk, adding an Ounce of Camphirated Spirit of Wine, and two Drams of _Saccharum Saturni_, with two Scruples of Oil of Anise, and bathe the Entrails with this Fomentation very hot. Otherwise, Apply Animals cut open alive; or else boil Skeins of raw Thread in Milk, and foment 'em with this Decoction in like manner very hot. Before the Suture of Stitching of the Intestines is made, it is expedient to foment 'em with Spirit of Wine, in which a little Camphire hath been dissolv'd: But if they be mortify'd, they must not be sown up again, but fomented with Spirituous Liquors. No Clysters are to be given to the Patient, for fear {233} causing the Intestine to swell; but a Suppository may be apply'd: Or else he may make use of a Laxative Diet-Drink, if it be necessary to open his Body: He ought also to be very temperate and abstemious during the Cure, so as to take no other Sustenance than Broths and Gellies. If the Intestines cannot be put up again, the Wound is to be dilated, avoiding the White-Line, and that too at the bottom rather than at the Top, if it be above. To this purpose the Intestines are to be rank'd along the side of the Wound, and a Bolster is to be laid upon 'em dipt in warm Wine, which may be held by some Assistant. Then the Surgeon introduceth a channel'd Probe into the Belly, and takes a great deal of care to fix the Intestine between the Probe and the _Peritonæum_, which may be effected by drawing out the Intestine a little; then holding the Probe with his Left-hand, to fit a crooked Incision-Knife in its chanelling, he cuts the Teguments equally both on the outside and within, and thrusts back the Entrails alternately into the Wound with his Fore-Finger. The Stitch must be intermitted, being made with two crooked Needles threaded at each end with the same Thread. The Surgeon having at first put the Fore-Finger of his Left-Hand into the Belly, to retain the _Peritonæum_, Muscles, and Skin on the side of the Wound, passeth the Needle with his other Hand into the Belly, the Point of which is guided with the Fore-Finger, and penetrates very far: Then he likewise passeth the other {234} Needle thro' the other Lip of the Wound into the Belly, observing the same thing as in the former, and without taking his Fingers off from the Belly. If there are many Points or Stitches to be made, they may be done after the same manner, without removing the Fingers from the Part, whilst a Servant draws together the Lips of the Wound, and ties the Knots. Afterward the Wound may be dress'd, and the Preparatives or Dressings kept close to the Part with the Napkin and Scapulary. But the Patient must be oblig'd to lie on his Belly for some Days successively, to cicatrize the Wound thereof, or that of the Entrails. If the Intestine were entirely cut, it wou'd be requisite to sow it up round about the Wound, after such a manner that some part of it may always remain open; for if the Patient shou'd recover, his Excrements might be voided thro' the Wound; of which Accident we have an Example in a Soldier belonging to the Hospital _Des Invalides_ at _Paris_, who liv'd a long time in this Condition. * * * * * CHAP. XII. _Of the Operation of the _Exomphalus_._ This Operation is necessary when the Intestines or Entrails have made a kind of Rupture in the Navel, and may be perform'd thus: When the Patient is laid upon his Back, an Incision is to be made on the Tumour to {235} the Fat, by griping the Skin, if it be possible, or else it may be done without taking it up. Then the Membranes are to be divided with a Fleam to lay open the _Peritonæum_, for fear of cutting the Intestine; and as soon as the _Peritonæum_ appears, it may be drawn upward with the Nails, in order to make a small Opening therein with some cutting Instrument: Whereupon the Surgeon having put the Fore-Finger of his Left-Hand into the Belly to guide the Point of the Sizzers, with which the Incision is enlarg'd, restores the Intestine to its proper Place, and loosens the Caul if it stick to the Tumour: But if the Entrails are fasten'd to the Caul, it is requisite to separate 'em by cutting a little of the Caul, rather than to touch the Intestine; which last being reduc'd, a Servant may press the Belly on the side of the Wound; so that if a Mass of Flesh be found in the Caul, which hath been form'd by the sticking of the Caul to the Muscles and _Peritonæum_, this Fleshy Mass must be entirely loosen'd, and then a Ligature may be made to take it away, with some part of the Caul, as we have already shewn in the _Gastroraphy_. Afterward the Stitch is to be made, as in that Operation, and the Wound must be dress'd, observing the same Precautions. The Dressing is to be supported in like manner with the Napkin and Scapulary. * * * * * {236} CHAP. XIII. _Of the Operation of the_ Bubonocele, _and of the compleat Rupture._ When the Intestinal Parts are fall'n into the Groin or the _Scrotum_, the Operation of the _Bubonocele_ may be conveniently perform'd; to which purpose the Patient is to be laid upon his Back, with his Buttocks somewhat high; then the Skin being grip'd a-cross the Tumour, the Surgeon holds it on one side, and the Assistant on the other, till he makes an Incision, following the Folds or Wrinkles of the Groin; when the Fat appears, it is requisite to tear off either with a Fleam or even with the Nails, every thing that lies in the way, till the Intestine be laid open, which must be drawn out a little, to see if it do not cleave to the Rings of the Muscles. The Intestine must be gently handl'd, to dissolve the Excrements; and those Parts must be afterward put up again into the Belly (if it be possible) with the two Fore-Fingers, thrusting 'em alternatively; but if they cannot be reduc'd, the Wound is to be dilated upward, by introducing a channell'd Probe into the Belly, to let the Sizzers into its Channelling. If the Probe cannot enter, the Intestine must be taken out a little, laying a Finger upon it near the Ring, and making a small Scarification in the Ring, with a streight Incision-Knife guided with the {237} Finger, to let in the Probe, into which may be put a crooked Knife, to cut the Ring; that is to say, to dilate the Wound on the inside; but care must be had to avoid penetrating too far, for fear of dividing a Branch of Arteries; and then the Parts may be put up into the Belly. If the Caul had caus'd the Rupture, it wou'd be requisite to bind it, and to cut off whatsoever is corrupted, scarifying the Ring on the inside, to make a good Cicatrice or Scar. _The Dressing and Bandage._ The Dressing may be prepar'd with a Linnen-Tent, soft and blunt, of a sufficient thickness and length, to hinder the Intestines from re-entring into the Rings by their Impulsion, a Thread being ty'd thereto, to draw it out as occasion serves. Then Pledgets are to be put into the Wound, after they have been dipt in a good Digestive, such as Turpentine with the Yolk of an Egg, applying at the same time a Plaister, a Bolster of a Triangular Figure, and the Bandage call'd _Spica_, which is made much after the same manner as that which is us'd in the Fracture of the Clavicle. _Of the compleat _Hernia_ or Rupture._ It happens when the Intestinal Parts fall into the _Scrotum_ in Men, or into the bottom of the Lips of the _Matrix_ in Women. To perform this Operation, the Patient must be laid upon his Back, as in the _Bubonocele_, and the Incision carry'd on after the same manner; which is to {238} be made in the _Scrotum_, tearing off the Membranes to the Intestine. Then a Search will be requisite, to observe whether any parts stick to the Testicle; if the Caul doth so, it must be taken off, leaving a little Piece on the Testicle; but if it be the Intestine, so that those Parts cannot be separated without hurting one of 'em, it is more expedient to impair the Testicle than the Intestine. If the Caul be corrupted, it must be cut to the sound Part, and the Wound is to be dress'd with Pledgets, Bolsters, and the Bandage _Spica_; as in the _Bubonocele_. * * * * * CHAP. XIV. _Of the Operation of _Castration_._ The Mortification or the _Sarcocele_ of the Testicles, gives occasion to this Operation; to perform which, the Patient must be laid upon his Back, with his Buttocks higher than his Head, his Legs being kept open, and the Skin of the _Scrotum_ taken up, one end of which is to be held by a Servant, and the other by the Surgeon, who having made a longitudinal Incision therein, or from the top to the bottom, slips off the Flesh of the _Dartos_ which covers the Testicle, binds up the Vessels that lie between the Rings and the Tumour, and cuts 'em off a Fingers breadth beneath the Ligature: But care must be taken to avoid tying the Spermatick Vessels too hard, for fear of a Convulsion, and {239} to let one end of the Thread pass without the Wound. If an Excrescence of Flesh stick to the Testicle, and it be moveable or loose, it is requisite to take it off neatly, leaving a small Piece of it on the Testicle; and if any considerable Vessels appear in the Tumour, they must be bound before they are cut. _The Dressing and Bandage._ The Dressing is made with Pledgets and Bolsters laid upon the _Scrotum_; and the proper Bandage is the _Suspensor_ of the _Scrotum_, which hath four Heads or Ends, of which the upper serve as a Cincture or Girdle; and the lower passing between the Thighs, and fasten'd behind to the Cincture. There is also another Bandage of the _Scrotum_, having in like manner four Heads, of which the upper constitute the Cincture; but it is slit at the bottom, and hath no Seams; the lower Heads crossing one another, to pass between the Thighs, and to be join'd to the Cincture. Both these sorts of Bandages have a Hole to give Passage to the Yard. * * * * * {240} CHAP. XV. _Of the Operation of the Stone in the_ Ureter. If the Stone be stopt at the _Sphincter_ of the Bladder, it ought to be thrust back with a Probe: If it stick at the end of the _Glans_, it may be press'd to let it out; and if it cannot come forth, a small Incision may be made in the opening of the _Glans_ on its side. But if the Stone be remote from the _Glans_, it is requisite to make an Incision into the _Ureter_; to which purpose, the Surgeon having caus'd the Skin to be drawn upward, holds the Yard between two Fingers, making a Longitudinal Incision on its side upon the Stone, which must be prest between the Fingers to cause it to fly out; or else it may be taken out with an _Extractor_. Then if the Incision were very small, the Skin needs only to be let go, and it will heal of it self; but if it were large, a small Leaden Pipe is to be put into the _Ureter_, lest it shou'd be altogether clos'd up by the Scar: It is also expedient to anoint the Pipe with some Desiccative Medicine, and to dress the Wound with Balsam. Afterward a little Linnen-Bag or Case is to be made, in which the Yard is to be put, to keep on the Dressing; but it must be pierc'd at the end, for the convenience of making Water, having two Bands at the other end, which are ty'd round about the Waste. * * * * * {241} CHAP. XVI. _Of the Operation of _Lithotomy_._ This Operation is undertaken when it is certainly known that there is a Stone in the Bladder; to be assur'd of which, it may not be improper to introduce a Finger into the _Anus_ near the _Os Pubis_, by which means the Stone is sometimes felt, if there be any: The Finger is likewise usually put into the _Anus_ of young Virgins, and into the _Vagina Uteri_ of Women, for the same purpose. But it is more expedient to make use of the Probe, anointed with Grease, after this manner: The Patient being laid on his Back, the Operator holds the Yard streight upward, the _Glans_ lying open between his Thumb and Fore-finger; then holding the Probe with his Right-hand on the side of the Rings, he guides it into the Yard, and when it is enter'd, turns the Handle toward the _Pubes_, drawing out the Yard a little, to the end that the Canal of the _Ureter_ may lie streight. If it be perceiv'd that the Probe hath not as yet pass'd into the Bladder, a Finger is to be put into the _Anus_, to conduct it thither. Afterward in order to know whether a Stone be lodg'd in the Bladder, the Probe ought to be shaken a little therein, first on the Right-side, and then on the Left; and if a small Noise be heard, it may be concluded for certain that there is a Stone: But if it be judg'd that the {242} Stone swims in the Bladder, so that it cannot be felt, the Patient must be oblig'd to make Water with a hollow Probe. Another manner of searching may be practis'd thus: Let the Yard be rais'd upward, inclining a little to the side of the Belly; let the Rings of the Probe be turn'd upon the Belly, and the end on the side of the _Anus_; and then let this Instrument be introduc'd, shaking it a little on both sides, to discover the Stone. In order to perform the Operation of Lithotomy, the Patient must be laid along upon a Table of a convenient height, so as that the Surgeon may go about his Work standing; the Patient's Back must also lean upon the Back of a Chair laid down, and trimm'd with Linnen-Cloth, lest it shou'd hurt his Body; his Legs must be kept asunder, and the Soles of his Feet on the sides of the Table, whilst a Man gets up behind him to hold his Shoulders: His Arms and Legs must be also bound with Straps or Bands. Then a channell'd Probe being put up into the Bladder, a Servant standing upon the Table on the side of the Chair, holds the Back of the Instrument between his two Fore-fingers on that Part of the _Perinæum_ where the Incision ought to be begun, which is to be made between his Fingers with a sharp Knife that cuts on both sides: The Incision may be three or four Fingers breadth on the left side of the _Raphe_ or Suture: But in Children its length must not exceed two Fingers breadth. If the Incision were too little to give Passage to the Stone, it wou'd be more expedient to enlarge it than to stretch the Wound {243} with the Dilatators. When the Convex Part where the channelling of the Probe lies, shall be well laid open, the Conductors may be slipt into the same Channelling, between which the _Forceps_ is to be put, having before taken away the Probe. Some Operators make use of a _Gorgeret_ or Introductor to that purpose, conveying the end of it into the Chanelling of the Probe; which is remov'd to introduce the _Forceps_ into the Bladder: And as soon as they are fixt therein, the Conductors or _Gorgeret_ must be likewise taken out. Afterward search being made for the Stone, it must be held fast, and drawn out of the Bladder: But if the Stone be long, and the Operator hath got hold thereof by the two Ends, he must endeavour to lay hold on it again by the Middle, to avoid the great scattering which wou'd happen in the Passage. The Stones are also sometimes so large, that there is an absolute necessity of leaving 'em in the Bladder. Again, if the Stone sticks very close to the Bladder, the Extraction ought to be deferr'd for some time; and perhaps it may be loosen'd in the Suppuration. Lastly, when the Stone hath been taken out, an Extractor is usually introduc'd into the Bladder, to remove the Gravel, Fragments, and Clots of Blood. After the Operation, the Patient is carry'd to his Bed, having before cover'd the Wound with a good Bolster; and if an Hæmorrhage happens, it is to be stopt with Astringents. A Tent must also be put into the Wound, when it is suspected that some Stone or Gravel may as yet remain therein: But if it evidently appears that {244} there is none, the Wound may be dress'd with Pledgets, a Plaister, and a Bolster, of a Figure convenient for the Part. The Dressing may be staid with a Sling supported by a Scapulary; or else the Bandage of the double T. may be us'd, the manner of the Application of which we have shewn elsewhere. The Patient's Thighs must be drawn close to one another, and ty'd with a small Band, lest they shou'd be set asunder again. The Operation of Lithotomy in Women is usually perform'd by the lesser Preparative, which is done by putting the Fore-finger and Middle-finger into the _Vagina Uteri_, or into the _Rectum_ in young Virgins, to draw the Stone to the Neck of the Bladder, and keep it steady, so that it may be taken out with a Hook, or other Instrument. This Operation may also be effected in Women, almost in the same manner as in Men; for after having caus'd the Female Patient to be set in the same Posture or Situation as the Men are usually plac'd, according to the preceeding Description, the Conductors may be convey'd into the _Ureter_, to let in the _Forceps_ between 'em, with which the Stone may be drawn out: But if it be too thick, a small Incision is to be made in the Right and Left side of the _Ureter_. The lesser Preparative was formerly us'd in the Lithotomy of Men, after this manner: The Finger was put into the _Anus_, to draw the Stone toward the _Perinæum_; then an Incision was made upon the Stone on the side of the Suture, and it was taken out with an Instrument. * * * * * {245} CHAP. XVII. _Of the Operation of the Puncture of the _Perinæum_._ This Operation is necessary in a Suppression of Urine, where the Inflammation is so great, that the Probe cannot be introduc'd. Then an Incision is to be made with the Knife or Lancet, in the same Place where it is done in Lithotomy; and a small Tube or Pipe is to be put in the Bladder, till the Inflammation be remov'd. * * * * * CHAP. XVIII. _Of the Operation of the _Fistula in Ano_._ Fistula's are callous Ulcers: If one of these happen in the Fundament, and is open on the outside, it may be cur'd thus: After the Patient hath been laid upon his Belly on the side of a Bed, with his Legs asunder, the Surgeon makes a small Incision with his Knife in the Orifice of the _Fistula_, in order to pass therein another small crooked Incision-Knife, at the end of which is a Pointed Stilet with a little Silver Head which covers it, to the end that it may enter without causing Pain. When the Surgeon hath convey'd his Knife into the {246} _Fistula_, having the Fore-finger of his Left-hand in the _Anus_ or Fundament, he pulls off its Head, holding the Handle with one Hand, and the Stilet that pierceth the _Anus_ with the other; and at last draws out the Instrument to cut the _Fistula_ entirely at one Stroke. If the _Fistula_ hath an Opening into the Intestine, an Incision is to be made on the outside at the Bottom thereof, to open it in the Place where a small Tumour or Inflammation usually appears, or else in the Place where the Patient feels a Pain when it is touch'd. If the Tumour be remote from the _Anus_, it may be open'd with the Potential Cautery, to avoid a greater Inconvenience. After having thus laid open the very bottom, the little Incision-Knife and Stilet, with its Head, is to be pass'd therein, the end of the Stilet is to be drawn thro' the _Anus_, and the Flesh is to be cut all at once. But if the _Fistula_ be situated too far forward in the Fundament, the _Sphincter_ of the _Anus_ must not be entirely cut, otherwise the Excrements cannot be any longer retain'd. Lastly, when the _Fistula_ hath been treated after this manner, all its Sinuosities or Winding-Passages ought likewise to be open'd, and the Wound being fill'd with thick Pledgets steept in some Anodyn, is to be cover'd with a Plaister and a Triangular Bolster; as also with the Bandage call'd the T. * * * * * {247} CHAP. XIX. _Of the Suture or Stitching of a _Tendon_._ It is requisite to undertake this Operation when the Tendons are cut, and when they become very thick. If the Wound be heal'd, it must be open'd again to discover the Tendon, and the Part must be bended, to draw together again the ends of the Tendons. Then the Surgeon taking a flat, streight, and fine Needle, with a double waxed Thread, passeth it into a small Bolster, and makes a Knot at the end of the Thread, to be stopt upon the Bolster. Afterward he pierceth the Tendon from the outside to the inside, at a good distance, lest the Thread shou'd tear it, and proceeds to pass the Needle in like manner under the other end of the Tendon, upon which is laid a small Bolster, for the Thread to be ty'd in a Knot over it. Then he causeth the Extremities of the Tendons to lie a little one upon another, by bending the Part, and dresseth the Wound with some Balsam. It may not be improper here to observe, that Ointments are never to be apply'd to the Tendons, which wou'd cause 'em to putrifie, but altogether Spirituous Medicaments; and that the Part must be bound up, lest the Extension of it shou'd separate the Tendons. * * * * * {248} CHAP. XX. _Of the _Cæsarian_ Operation._ When a Woman cannot be deliver'd by the ordinary means, this bold and dangerous Operation hath been sometimes perform'd with good Success. The Woman being laid upon her Back, the Surgeon makes a Longitudinal Incision beneath the Navel, on the side of the White-Line, till the _Matrix_ appears, which he openeth, taking great care to avoid wounding the Child: Then he divides the Membranes with which it is wrapt up, separates the After-Burden from the _Matrix_, and takes out the Child. Lastly he washeth the Wound with warm Wine, and dispatcheth the _Gastroraphy_ or Stitching up of the Belly, without sowing the _Matrix_. After the Operation, Injections are to be made into the _Matrix_, to cause a Flux of Blood; and a pierc'd Pessary must be introduc'd into its Neck. * * * * * {249} CHAP. XXI. _Of the Operation of _Amputation_, with its proper Dressings and Bandages._ The Leg is usually cut off at the Ham; the Thigh as near as can be to the Knee; and the Arm as near as is possible to the Wrist: But an Amputation is never made in a Joynt, except in the Fingers and Toes. In order to cut off a Leg, the Patient is to be set on the side of his Bed, or in a Chair, and supported by divers Assistants; one of 'em being employ'd to hold the Leg at the bottom, and another to draw the Skin upward above the Knee, to the end that the Flesh may cover the Bone again after the Operation. In the mean while a very thick Bolster is laid under the Ham, upon which are made two Ligatures, _viz._ the first above the Knee, to stop the Blood, by screwing it up with the _Tourniquet_ or _Gripe-Stick_; and the second below the Knee, to render the Flesh firm for the Knife. Before the Ligature is drawn close with the _Gripe-Stick_, a little piece of Paste-board is to be put underneath, for fear of pinching the Skin. Thus the Leg being well fixt, the Surgeon placeth himself between both the Legs of the Patient, to make the Incision with a crooked Knife, turning it circularly to the Bone, and laying one Hand upon the Back of the Knife, which must have no Edge. Afterward the _Periosteum_ is to be {250} scrap'd with an Incision-Knife, and the Flesh with the Vessels that lie between the two Bones are to be cut. When the Flesh is thus separated, a Cleft Band is to be laid upon it, with which the Heads are cross'd, to draw the Flesh upward, to the intent that the Bones may be cut farther, and that it may cover 'em after the Amputation, as also to facilitate the Passage of the Saw. Then the Surgeon holds the Leg with his Left-hand, and saweth with his Right, which he lets fall upon the two Bones, to divide 'em asunder at the same time, beginning with the _Perone_ or _Fibula_, and ending with the _Tibia_. But it is necessary to incline the Saw, and to go gently in the beginning, to make way for it, and afterward to work it faster. The Leg being cut off, the Ligature must be unty'd below the Knee, loosening the _Gripe-Stick_, to let the Blood run a little, and to discern the Vessels with greater facility; and then the _Gripe-Stick_ may be twisted again, to stop the Blood; which some Surgeons effect, by laying Pieces of Vitriol upon the Opening of the Arteries, and Astringent Powders, on a large Bolster of Cotton or Tow, to be apply'd to the end of the Stump; but if such a method be us'd, it is requisite that some Person be employ'd to keep on the whole Dressing with his Hand during twenty four Hours. However this Custom hath prevail'd in the Hospital of _Hôtel-Dieu_ at _Paris_. Others make a Ligature of the Vessels, taking up the ends of 'em with a pair of _Forceps_, having a Spring; or with the _Valet a Patin_, which is a sort of Pincers that are clos'd with a small {251} Ring let down to the bottom of the Branches. These Pincers being held by a Servant, the Surgeon passeth a Needle with wax'd Thread, into the Flesh, below the Vessel, bringing it back again, and with the two ends of the Thread makes a good Ligature upon the same Vessel; then he looseth the _Gripe-Stick_ and the Band, the Stump is to be somewhat bended, and the Flesh let down to cover the Bones. _The Dressing and Bandage._ After the Operation, it is requisite to lay small Bolsters upon the Vessels, and dry Pledgets upon the two Bones, as also many other Folds of Linnen strew'd with Astringent Powders; and over all another large Bolster or Pledget of Cotton or Tow, cover'd in like manner with Astringent Powders; then the whole Dressing is to be wrapt up with a Plaister and a Bolster, in form of a _Malta_ Cross; so that there are three or four Longitudinal Bolsters, and one Circular. The Surgeon usually begins to apply the _Malta_ Cross and Bolster under the Ham, crossing the Heads or Ends upon the Stump, and causeth 'em to be held by a Servant that Supports the Part; then he likewise crosseth the other Heads, and layeth on the two Longitudinal Bolsters that cross each other in the middle of the Stump, together with a third Longitudinal, which is brought round about the Stump, to stay the two former: These Bolsters ought to be three Fingers broad, and very long, to pass over the Stump. Afterward he proceeds to apply, {252} _The Bandage commonly call'd _Capeline_ by _French_ Surgeons, or the Head-Bandage._ Which is prepar'd with a Band four Ells long, and three Fingers broad, roll'd up with one Ball, three Circumvolutions being made on the side of the cut Part, the Band is to be carry'd upward with Rollers, passing obliquely above the Knee; and is brought down again along its former Turns; If it be thought fit to make this Bandage with the same Band, it must be let down to the middle of the cut Part, and carry'd up again to the Knee, many back-folds being made, which are stay'd with the Circumvolutions, till the Stump be entirely covered, and the whole Bandage wrapt up with Rollers or Bolsters. The _Capeline_ or Head-Bandage, having two Heads, is made with a Band of the same breadth, but somewhat longer. This Band being at first apply'd to the middle of the cut Part or Wound, the Heads are carry'd up above the Knee; and one of the Ends are turn'd backward, to bring it down, and to pass it over the end of the Stump. At every back-fold which is form'd above and below the Knee, a Circumvolution is to be made with the other end of the Band, to strengthen the back-folds, continuing to bring the Band downward and upward, till the whole Stump be cover'd: Then Rollers are made round about the Stump, and the Band is stay'd above the Knee. Afterward the Part may be brought to Suppuration, cleans'd and cicatriz'd. * * * * * {253} CHAP. XXII. _Of the Operation of the _Aneurism_._ This Operation is perform'd when the Surgeon hath prickt an Artery, or when a Tumour ariseth in an Artery. To this purpose the Patient is set in a Chair, and a Servant employ'd in holding his Arm in a Posture proper for the Operation; then a Bolster is to be laid four double, following the Progress of the Artery, to the end that the Ligature may better press the Vessel; and the Arm may be also surrounded with another single Bolster, on which is made a Ligature screw'd up with a _Gripe-Stick_, provided the Arm be not too much swell'd; for in this Case it wou'd be more expedient to deferr the Operation for fear of a Gangrene. The Artery being thus well stopt, the Surgeon lays hold on the Arm with one Hand, below the Tumour, and with the other makes an Incision with his Lancet, beginning at the bottom of the Tumour, and ending on the top along the Progress of the Artery. When the Tumour is open'd, the coagulated Blood may be discharg'd with a Finger; and if there are any Strings at the bottom, they may be cut with a crooked Pair of Sizzers, to the end that all the Clods of Blood, and other extraneous Bodies which are sometimes form'd in _Aneurisms_ when they are very inveterate may be more {254} easily remov'd. But the _Gripe-Stick_ must be loosen'd, to discover the Opening of the Artery with greater facility, and the Artery separated from the Membranes with a Fleam; for it wou'd be dangerous to cut it with a streight Incision-Knife: The Artery must also be supported with a convenient Instrument to divide it from the Nerve and Membranes; and to be assur'd of the Place of its Opening, the _Gripe-Stick_ may be somewhat loosen'd, and afterward screw'd up again. In the mean time the Surgeon gives the Instrument to a Servant to hold, whilst he passeth under the Artery a crooked Needle with a wax'd String, cuts the Thread, and takes away the Needle: Then he begins to make the Ligature beneath the Opening of the Artery, tying at first a single Knot, on which may be put (if you please) a small Bolster, that may be kept steady with two other Knots: It is also necessary that another Ligature be made in the lower part of the Artery, by reason that the little lateral Arteries might otherwise let out Blood. The Artery ought not to be cut between the two Ligatures, lest the first Ligature shou'd be forc'd by the Impulsion of the Blood; but the Thread must be let fall, that it may rot with the Suppuration. Then the Wound may be dress'd with Pledgets, Bolsters strew'd with Astringent Powders and a Plaister; a Bolster being also laid in the Fold of the Elbow. {255} _The Bandage_ Is made with a Band six Ells long, and an Inch broad, roll'd with one end, being at first apply'd with divers Circumvolutions under the Elbow, and moderately bound. Many turns are to be made, and a thick and streight Bolster, is to be laid upon the Tumour, (as in the Bandage for Phlebotomy) along the Artery, till it pass under the Arm-Hole: The Arm and Bolster must be surrounded with the Band, which is brought up with small Rollers, to the Arm-Pit, and stay'd with Circumvolutions round about the Breast. Afterward the Patient is to be laid in his Bed, with the Arm lying somewhat bended on the Pillow, and the Hand a little higher than the Elbow. * * * * * CHAP. XXIII. _Of the Operation of _Phlebotomy_._ To perform this Operation, the Surgeon holds the Lancet between his Thumb and Fore-finger, and three other Fingers lying upon the Patient's Arm, and thrusts the Point of the lancet into the Vessel, carrying the same Point somewhat upward, to make the Orifice the greater. If a Tendon, which is known by its hardness; or an Artery, which is discover'd by Pulsation, appear beyond the Vein, and very near it, the Lancet must be only set very {256} forward in the Vein, and drawn back again streight, without turning it up, otherwise the Artery or Tendon wou'd be certainly cut with the Point. If the Artery or Tendon lies immediately under the Vein, the later must be prickt somewhat underneath, holding the Lancet inclin'd side-ways, and thrusting it very little forward; so that the Point will finish the Opening, by turning it upward. If the Artery stick too close to the Vein, the later is to be prickt higher or lower than it is ordinarily done; and if the Vein be superficial, and lie close upon a hard Muscle, the Lancet must not be thrust downright into the Vein, but it is requisite to carry it somewhat obliquely, and to take the Vessel above, lest the Muscle and its Membrane shou'd be prickt, which wou'd cause a great deal of Pain, and perhaps a vehement Inflammation. It is well known that the Veins of the Right Arm are usually open'd with the Right-hand, and those of the Left-Arm with the Left-hand. _The Bandage_ Is made thus: The Surgeon having laid a Bolster upon the Orifice, keeps it close with two Fingers, and holds the Band or Fillet with the other Hand; then taking one end of the Fillet with the Middle-Finger, Fore-Finger, and Thumb, and applying it to the Bolster, he makes with the longest end of the Fillet divers Figures in form of the Letters KY in the Fold of the Arm; as also a back-fold with the shorter end of the Fillet, held between three {257} Fingers. Afterward both ends of the Fillet are ty'd beneath the Elbow. If an Inflammation happens after the Operation, the Bolsters are to be dipt in _Oxycratum_: but if the Orifice were so small as to produce a _Rhombus_, it wou'd be requisite to press the Wound often with two Fingers, and immediately to apply a Bolster dipt in _Oxycratum_. * * * * * CHAP. XXIV. _Of the Operation of _Encysted Tumours_._ If the Tumours are small and hanging, and have a narrow bottom, a Ligature may be made with Horse-Hair or Silk, dipt in _Aqua-Fortis_, which will cause 'em to fall off of themselves after some time; or else they may be cut above the Ligature. If the Tumour or Wen be thick, and its bottom large, a Crucial Incision is to be made in the Skin, without impairing the _Cystis_ or Bagg; and when the Incision is finish'd, the Bag may be torn off with the Nails, or with the Handle of a Pen-Knife; but sometimes it is necessary to dissect it. If there be any considerable Vessels at the Root, they may be bound, or else cut; and the Blood may be stopt with Astringents. If any parts of the _Cystis_ remain, they are to be consum'd with Corrosives; and the Lips of the Wound are to be drawn together without a Stitch, making use {258} only of an agglutinative Plaister. But if the Tumour adheres very close to the _Pericranium_, it is most expedient not to meddle with it at all. _Of _Ganglions_._ _Ganglions_ are Tumours arising upon the Tendons and Nervous Parts, which may be cur'd by thrusting 'em violently, and making a very streight Bandage, provided they be very recent; a resolvent Plaister is to be also apply'd to the Part. * * * * * CHAP. XXV. _Of the Operation of the _Hydrocephalus_._ This Operation is perform'd when it is necessary to discharge watry Humours out of the Head: If these Waters lie under the Skin, a very large Opening is to be made with a Lancet, and a small Tube or Pipe left therein to let 'em run out. If the Water be situated between the Brain and the _Dura Mater_, the Membrane is to be perforated with a Lancet, after the Trepan hath been apply'd, according to the usual Method, of which we have already given some account: Cauteries and Scarifications may be also us'd to very good purpose in this Disease. * * * * * {259} CHAP. XXVI. _Of the operation of cutting the Tongue-String._ When the Ligament of the Tongue in Infants is extended to its Extremity, they cannot suck without difficulty; and when grown up, they have an impediment in their Speech. This Ligament may be cut with a little pair of Sizzers; to which purpose the Thumb of the Left-hand being laid upon the Gum of the lower Jaw, to keep the Mouth open, the Tongue may be rais'd upward with the Fore-Finger of the same Hand, and the Sizzers may be pass'd between the two Fingers, to divide the String as near as is possible to the Root of the Tongue, avoiding the Vessels: If an Hæmorrhage happens, recourse may be had to Styptick-Waters. Afterward the Nurse must take care to let a Finger be often put into the Child's Mouth, to prevent the re-uniting of the String. * * * * * {260} CHAP. XXVII. _Of the Operation of opening stopt _Ductus_'s._ If there be only one Membrane that stops the Entrance of the _Vagina_, an Incision may be made, and a Leaden Pipe put into it, having Rings to fasten it to the Waste, to hinder the re-uniting of the Wound. If the Lips of the _Pudendum_ are conglutinated or clos'd up, the Patient must be laid upon her Back, and her Knees rais'd up, in order to make an Incision with a crooked Incision-Knife, beginning at the Top; and then a Leaden Pipe is to be put into the Opening. If the _Vagina_ be fill'd with a Fleshy Substance, an Incision is to be made therein, till it be entirely perforated, putting at the same time a Leaden Tube into the Orifice. If the Urinary _Ductus_ as well in young Boys as in Virgins, be stopt up, an Incision is to be made therein with a very narrow Lancet; and if a small Leaden Pipe can be conveniently introduc'd, it may be done; but it is not very necessary, in regard that Children are almost always making Water, which wou'd of it self hinder the closing of the Orifice. If the _Ductus_ of the Ear be stopt with a Membrane, it must be perforated, taking care not to go too far, for fear of piercing the Membrane of the _Tympanum_ or Drum, and {261} a small Leaden Pipe is to be put into the Opening. If there be a carnous Excrescence on the outside of the Ear, a Ligature ought to be made therein, or else it may be cut with a pair of Sizzers, to cause it to fall off; and the rest of the Fleshy Substance that remains in the Ear must be consum'd with Causticks, convey'd to the Part by the means of a small Tube, care being had, nevertheless, to avoid cauterizing the _Tympanum_. * * * * * CHAP. XXVIII. _Of the Operation of the _Phimosis_ and _Paraphimosis_._ When the _Præputium_ is so streight that the _Glans_ can be no longer uncover'd, this Indisposition is call'd _Phimosis_; but if the _Præputium_ be turn'd back above the _Glans_, after such a manner that it can no longer cover the same _Glans_, it is a _Paraphimosis_. If in the _Phimosis_ the _Præputium_ cleaves very close round about the _Glans_, it is most expedient to let it alone; but if in handling the _Glans_ it be perceiv'd that it is moveable, or else that some parts of it only stick together, the Operation may be perform'd after this manner: The Patient being set in a Chair, a Servant is employ'd in pulling back the Skin to the Root of the _Penis_, to the end that the Incision may be {262} made directly at the bottom of the _Glans_: Then the Surgeon having drawn out the bottom of the _Præputium_, introduceth a small Instrument with a very sharp Point on its flat side, at the end of which is fixt a Button of Wax, pierceth the _Præputium_ at the bottom of the _Glans_ on the side of the Thread, and finisheth the Incision by drawing the Instrument toward himself. The _Paraphimosis_ is cur'd by making Fomentations on the Part, to allay the Inflammation if there be any; and it is to be pull'd down with the Fingers. But if Medicinal Preparations prove ineffectual, Scarifications are to be made round about the _Præputium_; and afterward convenient Remedies may be apply'd to remove the Inflammation, and prevent the Mortification of the Part; so that at length the _Præputium_ may be drawn over the _Glans_. * * * * * CHAP. XXIX. _Of the Operation of the _Varix_._ In order to cure this Tumour, the Surgeon having first cut the Skin to discover the dilated Vein, separates it from the Membranes, and passeth underneath a crooked Needle with a double wax'd Thread; then he makes a Ligature both above and below the dilatation of the Vein, opens the dilated Part with a Lancet, to let out the Blood, and applies a convenient Bandage: But without performing this {263} Operation, the Vein might be open'd with a Lancet, to draw out a sufficient quantity of Blood; and then the _Varix_ is to be press'd with a somewhat close Bandage. * * * * * CHAP. XXX. _Of the Operation of the _Panaritium_._ The _Panaritium_ is an Abcess which ariseth at the end of the Fingers; some of these Tumours are only superficial, and others penetrate even under the _Periosteum_; nevertheless after whatsoever manner the _Panaritium_ may happen, it ought to be open'd on the side of the Finger, that the Tendons may not be hurt. If the Abcess be extended under the _Periosteum_, the opening must be made on the side, and the Lancet thrust forward to the Bone: Afterward the _Pus_ or corrupt Matter is to be discharg'd, which wou'd cause the Tendons to putrifie, if it shou'd remain too long upon 'em. _The Dressing and Bandage_ Are made with a Plaister cut in form of a _Malta_ Cross, which is apply'd at the middle to the end of the Finger, the Heads being cross'd round about. The Bolsters must be also cut in the shape of the _Malta_ Cross, or of a plain Cross only; the Band being a Finger's breadth {264} wide, and long enough to be roll'd about the whole Dressing: It must be pierc'd at one of its ends, and cut the length of three Fingers at the other; so that the two Heads may pass thro' the Hole, to surround the Finger with small Rollers. * * * * * CHAP. XXXI. _Of the Reduction of the falling of the _Anus_._ To reduce the _Anus_ to its proper place when it is fallen, the Patient being laid upon his Belly, with his Buttocks higher than his Head, the Operator gently thrusts back the Roll that forms the _Anus_ with his Fingers dipt in the Oil of Roses: Then he applies the Bolsters steept in some Astringent Liquor, and causeth 'em to be supported with a sort of Bandage, the Nature of which we shall shew in treating of the Fracture of the _Coccyx_, that is to say, the T. the double T. or else the Sling with four Heads. * * * * * {265} CHAP. XXXII. _Of the Reduction of the falling of the _Matrix_._ In this Operation, the Patient being laid upon her Back, with her Buttocks rais'd up, Fomentations are to be apply'd to the Part; a Linnen Cloth is to be laid upon the Neck of the fallen _Matrix_; and it is to be thrust very gently with the Fingers, without using much force. If the _Matrix_ shou'd fall out again, it wou'd be requisite to convey a Pessary into it, after it hath been reduc'd; and to enjoyn the Patient to lie on her Back with her legs a-cross. * * * * * CHAP. XXXIII. _Of the Application of the _Cautery_._ The Cautery is an Ulcer which is made in the Skin, by applying Causticks to it, after this manner: The Surgeon having moisten'd the Skin for a while with Spittle, or else having caus'd a light Friction to be made with a warm Cloth, applies a perforated Plaister to the Part, and breaks the Cautery-Stone, to be laid in {266} the little Hole, leaving it for a longer or shorter time, accordingly as he knows its Efficacy, or as the Skin is more or less Fine. Afterward he scarifieth the Burn with his Lancet, and puts a Suppurative, or piece of fresh Butter into the Part, till the Escar be fallen off. _The Dressing and Bandage._ After the Application of the _Lapis Infernalis_, or any other Cautery-Stone, it is necessary to lay over it a Plaister, a Bolster, and a Circular Bandage, which ought to be kept sufficiently close, to press the Stone, after a Pea or little Piece of Orrice-Root, hath been put into the Ulcer to keep it open. Then the Patient is to make use of this Bandage, with which he may dress it himself. Take a piece of very strong Cloth, large enough to roll up the Part without crossing above it: And let three or four Holes be made in one of its sides, as many small Ribbans or Pieces of Tape being sow'd to the other, which may be let into the Holes, as occasion serves, to close the Band. * * * * * {267} CHAP. XXXIV. _Of the Application of Leeches._ It is requisite that the Leeches be taken in clear running Waters, and that they be long and slender, having a little Head, the Back green, with yellow Streaks, and the Belly somewhat reddish. Before they are apply'd, it is also expedient to let 'em purge during some Days in fair Water, fast half a Day in a Box without Water. Afterward the Part being rubb'd or chaf'd with warm Water, Milk, or the Blood of some Fowl, the Opening of the Box is to be set to the Part, or the Leeches themselves laid upon a Cloth; for they will not fasten when taken up with the Fingers. The end of their Tail may be cut with a Pair of Sizzers, to see the Blood run, and to determine its quantity, as also to facilitate their sucking. When you wou'd take 'em away, put Ashes, Salt, or any other sharp thing upon their Head, and they will suddenly desist from their Work; but they are not to be pull'd off by force, lest they shou'd leave their Head or Sting in the Wound, which wou'd be of very dangerous consequence. When they are remov'd, let a little Blood run out, and wash the Part with salt Water. {268} _The Dressing_ Is made with a Bolster soakt in some Styptick Water, if the Blood will not otherwise stop; or in Brandy or _Aqua-Vitæ_ if there be an Inflammation; and it is to be supported with a Bandage proper for the Part. * * * * * CHAP. XXXV. _Of the Application of the _Seton_._ To perform this Operation, a Cotton or Silk Thread is to be taken, after it hath been dipt in Oil of Roses, and let into a kind of Pack-Needle; then the Patient sitting in a Chair, is to hold up his Head backward, whilst the Surgeon gripes the Skin transversely in the Nape of the Neck with his Fingers, or else takes it up with a Pair of _Forceps_, and passeth the Needle thro' the Holes of the _Forceps_, leaving the String in the Skin. As often as the Bolster that covers the Seton is taken off, that part of the String which lies in the Wound is to be drawn out, and cut off. * * * * * {269} CHAP. XXXVI. _Of _Scarifications_._ Scarifications are to be made more or less deep, accordingly as necessity requires, beginning at the bottom, and carrying them on upward, to avoid being hinder'd by the Hæmorrhage. They must also be let one into another, that Strings may not be left in the Skin. * * * * * CHAP. XXXVII. _Of the Application of _Vesicatories_._ Vesicatories are compounded with the Powder of Cantharides or Spanish flies, mixt with very sower Leaven, or else with Turpentine. Before they are apply'd, a light friction is to be made on the Part with a warm cloth, and a greater or lesser quantity is to be laid on, accordingly as the Skin is more or less fine, leaving 'em on the Part about seven or eight Hours; then they are to be taken away, and the Blisters are to be open'd, applying thereto some sort of Spirituous Liquor. * * * * * {270} CHAP. XXXVIII. _Of the Application of _Cupping-Glasses_._ A Good Friction being first made with warm Clothes, lighted Toe is to be put into the Cupping-Glass, or else a Wax-Candle fasten'd to a Counter, and then it is to be apply'd to the Part till the Fire be extinguish'd, and the Skin swell'd, re-iterating the Operation as often as it is necessary; and afterward laying on a Bolster steept in Spirit of Wine. These are call'd dry Cupping-Glasses: But if you wou'd draw Blood, every thing is to be observ'd that we have now mention'd, besides that Scarifications are to be made, according to the usual manner; and the Cupping-Glass is to be set upon the Scarifications: But when the Cupping-Glass is half full of Blood, it must be taken off to be emptied, and the Application thereof is to be re-iterated, as often as it is required to take away any Blood. Lastly, the Incisions are to be wash'd with some Spirituous Liquor; and a Bandage is to be made convenient for the Part. * * * * * {271} CHAP. XXXIX. _Of the opening of _Abcesses_ or _Impostumes_._ An Abcess or Impostume ought to be open'd in its most mature part, and in the Bias of the Humours, endeavouring to preserve the Fibres of the Muscles from being cut, unless there be an absolute necessity, avoiding also the great Vessels, Tendons, and Nerves. The Opening must be rather large than small, and not too much press'd in letting out the purulent Matter. If the Skin be thick, as it happens in the Heel, it may be par'd with a Razor; and if the Matter be lodg'd under the Nails, it wou'd be required to scrape 'em with Glass before they are pierc'd. * * * * * {272} A TREATISE OF THE OPERATIONS OF FRACTURES. * * * * * CHAP. I. _Of the Fracture of the Nose._ When the Fracture is considerable, the Nostrils are stopt up, and the Sense of Smelling is lost. In order to reduce it, the Surgeon takes a little Stick wrapt up in Cotton, and introduceth it into the Nostrils as gently as is possible, to raise up the Bones again, laying the Thumb of his Left-hand upon the Nose, to retain 'em in their place. The Bones being thus set, he proceeds to prepare {273} _The Dressing and Bandage_ By conveying into the Nostrils certain Leaden Pipes of a convenient Bigness and Figure, which serve to support the Bones, and to facilitate Respiration. But care is to be had to avoid thrusting 'em up too far, for fear of hurting the sides of the Nose; and they are to be anointed with Oil of Turpentine mixt with Spirit of Wine: These Pipes are also to have little Handles, with which they may be fasten'd to the Cap. If there be no Wound in the Nose, there will be no need of a Bandage; but if the Fracture be accompany'd with a Wound, after having apply'd the proper Medicines, it wou'd be requisite to lay upon each side of the Nose a Triangular Bolster, cover'd with a little piece of Paste-board of the same Figure. This small Dressing is to be supported with a kind of Sling that hath four Heads; being a piece of Linnen-Cloath, two Fingers broad, and half an Ell long; it is slit at both ends, and all along, only leaving in the middle a Plain of three Fingers, that is to say, a part which is not cut. The Plain of this Sling is to be laid upon the Fracture, causing the upper Heads to pass behind the Nape of the Neck, which are to be brought back again forward; the lower Heads are likewise to be carry'd behind, crossing above the upper, and afterward to be return'd forward. If the Bones of the Nose be not timely reduc'd, a great Deformity soon happens therein, and a Stink caus'd by the Excrescences and _Polypus's_. * * * * * {274} CHAP. II. _Of the Fracture of the lower Jaw._ The Operator at first puts his Fingers into the Patient's Mouth, to press the Prominences of the Bones; and afterward doth the same thing on the outside. If the Bones pass one over another, a small Extension is to be made. If the Teeth be forc'd out of their Place, they are to be reduc'd, and fasten'd to the sound Teeth with a wax'd Thread. _The Dressing and Bandage._ If the Fracture be only on one side, a Bolster sow'd to a piece of Paste-board is to be laid upon the flat side of the Jaw, both being of the Figure and Size of the Jaw it self. The Bandage of this Fracture is call'd _Chevestre_, i.e. _a Cord or Bridle_, by the _French_ Surgeons, and is made by taking a Band roll'd with one Head or End, three Ells long, and two Fingers broad; the Application of it is begun with making a Circumvolution round about the Head in passing over the Fore-head; then the Band is let down under the Chin, and carry'd up again upon the Cheek, near the lesser Corner of the Eye in passing over the Fracture; afterward it is rais'd up to the Head, and brought down again under the Chin, {275} to form a Roller or Bolster upon the Fracture: Thus three or four Circumvolutions and Rollers being made upon the Fracture, the Band is let down under the Chin, to stay and strengthen its several Turns, and is terminated round the Head, in passing over the Fore-head. If the Jaw be fractur'd on both sides, it wou'd be requisite to apply thereto a Bolster and Paste-board, perforated at the Chin, and of the Figure of the entire Jaw; the Bandage which we have even now describ'd, may be also prepar'd in making Rollers on both sides of the Jaw: Or else the double _Chevestre_ may be made with a Band of five Ells long, and two Fingers broad, roll'd up with two Balls, that is to say, with the two Ends. The Application of this Band is begun under the Chin, from whence it is carry'd up over the Cheek, cross'd upon the top of the Head, and brought down behind the Head, where it is cross'd again; then it is let down under the Chin, cross'd there, and carry'd up over the Fracture; afterward the Band being pass'd three or four times over the same turns, in making Rollers upon the Jaws, is turn'd upon the Chin, and stay'd upon the Forehead round about the Head. * * * * * {276} CHAP. III. _Of the Fracture of the _Clavicle_._ The Patient is to be set in a Chair, and his Arm is to be drawn backward, whilst an Assistant thrusts his Shoulder forward: In the mean time the Operator sets the Bones again in their place, by thrusting the Protuberances, and drawing out the sunk Bone. Or else a Tennis-Ball may be taken, and put under the Patient's Arm-Pit, whose Elbow is then to be press'd against his Ribs, whilst the Surgeon reduceth the Fracture. Otherwise, the Patient may be laid upon his Back, putting a Convex Body under both his Shoulders, as a Bowl, or large wooden Porrenger; and then the Shoulders may be prest, to raise up the two ends of the Bones, which the Surgeon must take care to reduce. _The Dressing and Bandage._ The Cavities which are above and below the Clavicle, are to be fill'd with Bolsters trimm'd with Paste-boards; another is to be also laid upon the Bone, which is almost of the same Figure with the Clavicle, and a large Bolster, to cover the three others: This Dressing is to be secur'd with the Bandage call'd the _Capeline_ or Head-Bandage, provided the Fracture be in the middle of the Clavicle. A Band {277} being taken about six Ells long, and four fingers thick, roll'd with two Balls; it is apply'd in the middle to the Fracture; one of its Heads or Ends is let down upon the Breast, whilst the other is pass'd behind the Back, below the Arm-hole, opposite to the indispos'd Arm-hole and above the Breast, to be carry'd over the other end of the Band, which is rais'd up, to make a Roller or Bolster upon the Fracture: The other end is pass'd under the indispos'd Arm-pit, and upon the Band that made the Roller, which is elevated by making a third Roller upon the Clavicle: These Circumvolutions around about the Body are continu'd, as also these Rollers upon the Clavicle, till it be entirely cover'd. Some Circumvolutions are also made upon the upper part of the Arm, near its Head: The Space that lies between the Rollers and the Circumvolutions of the Arm, and which bears the Name of _Geranium_ or Stork's-Bill, is likewise cover'd with some Circumvolutions, and the Band is stay'd by making Circumvolutions quite round about the Body. If the Fracture were near the Head of the _Humerus_ or Arm-Bone, a sort of Bandage might be prepar'd, which is call'd _Spica_, with a Band roll'd with one Ball five Ells long, and four fingers broad; one end of this Band is pass'd under the Arm-pit opposite to the indispos'd one behind the Back: The other end is convey'd under the indispos'd Arm-pit; the Figure of the Letters KY or X is made on the Shoulder; the Band is return'd below the other Shoulder behind; it is brought back again before, to form a second KY upon the {278} Fracture; three or four more KY's are wrought upon the Fracture; two Circumvolutions are made in the upper part of the _Humerus_, which constitute a Triangle call'd _Geranium_; this Triangle is cover'd with Rollers, and the Band is terminated round about the Breast. * * * * * CHAP. IV. _Of the Fracture of the _Omoplata_ or Shoulder-Blade._ The _Acromion_ is usually fractur'd, but it may be known that the middle of the _Omoplata_ is broken by a Numness which is felt in the whole Arm: Whereupon the Surgeon, after having examin'd the place of the Fracture, thrusts back the Prominences of the Bones into their place; and if any Splints happen to prick the Part, he makes an Incision to take 'em out, or to cut off their Points. _The Dressing and Bandage._ A Bolster is laid upon the _Omoplata_, as also a large piece of Paste-board of the bigness and Figure of this Bone, and a sort of Bandage is prepar'd, known by the name of _the Star_, with a Band roll'd with one Head four Ells long, and as many Fingers broad. This Band is convey'd behind the Back, one of its ends lying under the Arm-hole, opposite to the indispos'd one; but the other is pass'd under the {279} Shoulder, and afterward above it, to make a KY in the middle of the Back; then passing under the other Arm-hole, it is brought up to the Shoulder, to be let down, and to form a second KY upon the middle of the Back: These Turns are continu'd in making Rollers, till the _Omoplatæ_ are all cover'd: Circumvolutions are also made round the upper part of the _Humerus_, as in the _Spica_; and the Bandage is finish'd by Circumvolutions round about the Breast. * * * * * CHAP. V. _Of the Fracture of the Ribs._ When a Rib is broken, one of the ends pusheth into the Breast, sometimes on the outside; and sometimes the Ends lie against each other. In order to reduce it, the Patient being laid upon the sound Rib, a Plaister of Mastick is apply'd to the Fracture; and it is drawn out violently; so that sometimes this Attraction brings back the Bone, which is advanc'd into the Breast; but the surest way is to make an Incision therein, to raise it up with the Finger. If the Rib appear without, the Patient is to be set in a a Chair, and oblig'd to bend his Body on the side opposite to the Fracture, holding his Breath, with which he must puff strongly, without letting it forth, in order to dilate the Breast, whilst the Surgeon thrusts the Rib into its place. {280} _The Dressing and Bandage._ A Bolster is to be apply'd to the Fracture, with two little Pieces of Paste-board pass'd in form of a St. _Andrew's_ Cross; and another Bolster upon the whole Dressing, on which is also laid a large square Paste-board cover'd with a Bolster. The Bandage is made with a Napkin folded into three Folds, which is put round the Breast, being sow'd and supported by the Scapulary; which is a Band six Fingers broad, perforated in the middle, to let in the Head. The two ends of the Scapulary are fasten'd before and behind to the Napkin. * * * * * CHAP. VI. _Of the Fracture of the _Sternum_ or Breast-Bone._ To reduce this Fracture, the Patient is to be laid upon his Back, with a Convex Body underneath; both his Shoulders are to be press'd with some weight, to push 'em backward, and to raise up the _Sternum_, which is sunk down; or else an Incision may be made upon the Bone, to discover it; and then a _Vectis_ is to be apply'd thereto very gently, in order to heave it up into its place. {281} _The Dressing and Bandage._ A Bolster and Paste-board are to be laid upon the _Sternum_, almost of the same Figure with the Part; and the Bandage is to be prepar'd with a Napkin supported with a Scapulary. Or else the Bandage call'd _Quadriga_ may be made with a Band roll'd with two Heads, five Ells long, and four Fingers broad: The Application of this Band is begun under the Arm-pit; the Figure of KY is form'd under the Shoulder; the Band is carry'd downward with the two Balls, once before, and the other behind; it is pass'd under the other Arm-hole; the Heads are cross'd upon the Shoulder, and it is brought down backward and forward, forming a KY before and behind. Afterward the Bank is roll'd about the Breast in making Rollers or Bolsters; these Rollers are continu'd till the Band be terminated; and it is stay'd by a Cirumvolution round the Breast. * * * * * CHAP. VII. _Of the Fracture of the _Vertebra_'s._ The _Apophyses_ of the _Vertebra's_ are commonly broken, and their Bodies but seldom: It may be known that the Body of the _Vertebra_ of the Neck and Back is fractur'd by the Palsie of the Arm, accompany'd with the loss of Feeling; by the suppression of Urine; {282} and by the Palsie of the _Sphincter_ of the _Anus_; so that the Excrements cannot be any longer retain'd. If these Symptoms appear, it may well be conceiv'd that the Marrow is compress'd, and prickt with Points; for the removing of which, it is necessary to make an Incision upon the Body of the _Vertebra_ in the fractur'd Place. If the _Apophyses Spinosæ_ are only fractur'd, these Accidents will not happen, only some Pain will be felt: To reduce 'em, the Patient is to be laid upon his Belly, and the Surgeon must use his utmost endeavours to raise up the Bone again, and to set it in its Natural Situation. _The Dressing and Bandage._ If the _Apophysis Spinosa_ were fractur'd, it wou'd be requisite to apply to each side of it a small long Bolster, which is to be cover'd with a Paste-board of the same Figure with the Bolster; another Bolster lying upon each Paste-board. The Bandage is to be made with a Napkin sustain'd by its Scapulary; or else the _Quadriga_ may be prepar'd, according to the manner we have already describ'd in the Fracture of the _Sternum_. * * * * * {283} CHAP. VIII. _Of the Fracture of the _Os Sacrum_._ It is reduc'd as the other _Vertebra's_; but its Dressing and Bandage are made with the T perforated at the _Anus_, or else with the H or double T. It is made with a Band two Fingers broad, and long enough to encompass the Body above the Hips; so that to the middle of this Band is fasten'd another Band of the same breadth, and of a sufficient length to pass over the Dressing of the _Os Sacrum_, as also between the Thighs, to be join'd in the fore-part to the first Cincture. The double T is made by fastening two Bands at a Finger's breadth distance one from another, to the Band which ought to be roll'd about the Body; and this sort of Bandage is to be supported with a Scapulary. * * * * * CHAP. IX. _Of the Fracture of the _Coccyx_ or Rump-Bone._ This Bone is usually broken by falls, and sinks into the inside; so that to reduce it, the Fore-finger of one Hand is to be put into the _Anus_ or Fundament as far as the {284} Fracture, to thrust it back again into its place, whilst the other Hand setleth it on the outside. _The Dressing and Bandage._ Are the same with those in the Fracture of the _Os Sacrum_; but the Patient must be oblig'd to lie on one side, and to sit in a perforated Chair, when he hath a mind to rise. If the _Os Innominatum_ be broken, the _Spica_ is to be us'd after it hath been dress'd, of which Bandage we have given an Account in the Fracture of the Clavicle. * * * * * CHAP. X. _Of the Fracture of the _Humerus_ or Arm-Bone._ To set this Bone, a strong Extension is to be made, if the two ends cross one another, to which purpose the Patient is to be plac'd on a little Stool or Seat, and supported by a Servant, two other Assistants being employ'd to draw, one at the upper-part, and the other at the lower, above the Elbow, and not beneath it. In the mean time the Operator reduceth the two Bones, by closing 'em on all sides with the Palms of his Hands, and afterward prepareth {285} _The Dressing and Bandage._ It is necessary at first to lay round the Fracture a Bolster steept in some proper Liquor, as Claret or _Oxycratum_; then three several Bands are to be taken, three or four Fingers broad, and an Ell and a half long: The first of these is to be laid upon the Fracture, round which are to be made three very streight Circumvolutions; then it is to be carry'd up with small Rollers to the top of the Arm, and stay'd round the Body. The second Band being apply'd to the Fracture, on the side opposite to the first, two Circumvolutions are to be made upon the Fracture; so that the same Band may be brought down along the whole length of the Arm, making divers Rollers, and at last stay'd below the Elbow, which, nevertheless, it must not cover. Afterward our Longitudinal Bolsters must be laid upon the Fracture round about the Arm, which are to be kept close with a third Band; it being of no great Importance whether the Application of this third Band be begun at the Top or at the Bottom; but it may be stay'd round the Body, or else beneath the Elbow. The Arm ought also to be encompass'd with two thick pieces of Paste-board made round at the ends, and of the length of the Arm; but they must not cross one another. These Paste-boards are to be fasten'd with three Ribbands, and the Arm is to be put into a Scarf made with a large Napkin, which is to be first apply'd in the middle under the Arm-pit, the Arm resting upon it, so that {286} the four ends may be rais'd up, and fasten'd to the opposite Shoulder; but the Hand must lie higher than the Elbow. * * * * * CHAP. XI. _Of the Fracture of the Bone of the Elbow._ If both the Bones of the Elbow be broken, a stronger Extension is to be made than if only one of 'em were so hurt; to which purpose a Servant is to be appointed to grasp the Arm above the Elbow with both his Hands, and another to hold it above the Wrist, whilst the Surgeon sets the Bones with the Palms of both his Hands, till no unevenness be any longer felt in the Part. _The Dressing and Bandage_ Are the same with those in the Fracture of the Arm; but the Bands which are carry'd upward are to be stay'd above the Elbow. If the Patient be desirous to keep his Bed, it is requisite that his Arm be laid upon a Pillow, the Elbow lying somewhat higher than the Hand. * * * * * {287} CHAP. XII. _Of the Fracture of the _Carpus_ or Wrist-Bone._ If the Bones of the _Carpus_, or those of the _Metacarpium_ be fractur'd, a Servant must hold the Arm above the Wrist, and another the Fingers; whilst the Operator sets the Bones in their place, so as no unevenness may appear in the Part. _The Dressing and Bandage._ Of the Fracture of the Wrist are to be prepar'd with a Band roll'd with one Head, being six Ells Long, and two Fingers broad; so that three Circumvolutions are to be made upon the Wrist; the Band is to be pass'd over the Hand, between the Thumb and the Fore-finger, making the Figure of KY upon the Thumb. Then after having made divers Rollers upon the _Carpus_, a Bolster is to be apply'd, with a little Piece of Paste-board of the same Shape with the Wrist; several Rollers are to be form'd on the top of the Elbow, to stay the Band above it; and the Arm is to be put into a Scarf. * * * * * {288} CHAP. XIII. _Of the Fracture of the Bone of the _Metacarpium_._ Two Servants are to hold the Hand, after the same manner as in the setting of the _Carpus_ or Wrist-Bone, whilst the Surgeon reduceth the broken Bone by fixing it in its Natural Situation. _The Dressing and Bandage_ Are made with a Band roll'd up with one Head, five Ells long, and two Fingers broad: This Band being fasten'd to the Wrist, with a Circumvolution, is to be laid on the _Metacarpium_, between the Thumb and the Fore-finger, and the Figure of KY is to be made upon the Hand: Then the forming of Rollers and KY's is to be continu'd till the _Metacarpium_ be cover'd; a Bolster and Paste-board are to be laid upon the same _Metacarpium_; as also one in the Hand, of the Shape of the Part: The inside of the Hand is to be trimm'd; and the whole Contexture is to be cover'd as before, with Rollers; which are continu'd till above the Elbow, where the Band is stay'd. * * * * * {289} CHAP. XIV. _Of the Fracture of the Fingers._ A Light Extension is to be made in the Fingers to reduce 'em, and a small Dressing is to be prepar'd for every Finger, almost like that of the Arm. The Fingers are to be somewhat bent, and the inside of the Hand is to be trimm'd with a Bolster, to retain 'em in this Situation. The Bolster is also to be stay'd with a Band, and the Arm to be put into a Scarf. * * * * * CHAP. XV. _Of the Fracture of the Thigh._ If the Thigh-Bone be broken near its Head, the Fracture is very difficult to be discover'd; but if the Bone pass one over another, it may be soon known, because the hurt leg will be shorter than the other. Therefore a very great Extension is to be made; and if the Hands are not sufficient for that purpose, recourse may be had to Straps and Engines. In the mean time the Operator is to lay his Thumbs upon the fractur'd Bone, to thrust it back into its place, and afterward to apply {290} _The Dressing and Bandage._ The Cavity of the Thigh is to be fill'd with a thick Bolster, of the length of its bending; and three Bands four Fingers broad are to be provided, the first being three Ells long, and the second four, as well as the third: Then three Circumvolutions are to be made upon the Fracture with the first Band, carrying it up with small Rollers, and it is to be stay'd round the Body. The second Band is to make two Circumvolutions upon the Fracture, and is to be brought down with small Rollers, which are terminated above the Knee; or else they may be continu'd all along the Leg; it is also to be pass'd under the Foot, and to be drawn up again upon the Leg: Then a Bolster is to be apply'd to the lower part of the Thigh, being thicker at bottom than at top, to render the Thigh everywhere even; and four Longitudinal Bolsters are to be added, on which are laid Splints of the same length and breadth, which are to be wrapt up with a single Bolster. The third Band is to be roll'd upon these Splints, beginning at the bottom, and ascending with Rollers. Then two large Paste-boards are to be us'd, which may embrace the whole Dressing, without crossing one another, being fasten'd with three Ribbands. Afterward a Pair of Pumps is to be put under the Foot, and the Heel to be supported with a small Roll, the Thigh and Leg being let into the Scarves, the inner of which is to extend to the Groin, and the {291} outermost is to be somewhat longer: Two little Cushions are also to be laid on each side below the Knee, and two others below the Ankles, to fill up the Cavities. These Cushions or large Bolsters are to lie between the Scarves; and a thick Bolster is to be laid upon the Leg all along its length, as also on upon the Thigh. The Scarves are to be bound with three Ribbands for the Legs, and as many for the Thighs; the Knots being ty'd without, and on the side. * * * * * CHAP. XVI. _Of the Fracture of the Knee-Pan._ The Knee-Pan is cleft or broken in divers pieces in its length, and cross-wise: If it be broken cross-wise or obliquely, the two Pieces fly out one from another; and on this occasion a strong Extension is to be made; whilst the Surgeon at the same time thrusts back again the upper-part of the Knee-Pan into its place. If the Knee-Pan be fractur'd in its length, no Extension can be made, because the pieces of the Bones remain in their place. _The Dressing and Bandage._ If the Knee-Pan be broken cross-wise, a Band is to be provided three Ells long, and two Fingers Broad, which may be roll'd with {292} one or two Heads. The Application is to be begun above the Knee-Pan; the Figure of KY is to be made in the Ham, and a Circumvolution under the Knee; then the Band is to be continually carry'd up and down, till the Knee-Pan be entirely cover'd. If the Knee-Pan be fractur'd in its length, that is to say, from the top to the bottom, the Uniting-Band must be us'd, being two or three Ells long, and two Fingers broad, perforated in the middle. It is to be at first apply'd under the Knee, and one of the Balls is to be pass'd thro' the Hole; it must also be well clos'd, and divers Circumvolutions are to be made upon the Knee-Pan, so as it may be altogether cover'd. * * * * * CHAP. XVII. _Of the Fracture of the Leg._ If the _Tibia_ be only broken, it pushes into the Inside; but if both Bones be fractur'd they are sometimes separated on both sides, or else they pass one upon another; and in this case the Leg is shorter than it ought to be. If the _Perone_ be broken, it pushes to the outside. If one Bone be only fractur'd, so strong an Extension is not requisite as when they are both shatter'd, and it is to be drawn only on one side; whereas the drawing ought to be equal on both sides when both Bones are concern'd. {293} Thus whilst the Assistants are employ'd in drawing, the Surgeon performs the Operation, by laying the ends of the Bones exactly against one another; and they are known to be reduc'd when the great Toe remains in its Natural Situation. _The Dressing and Bandage._ A simple Bolster dipt in a convenient Liquor is at first apply'd, and three Bands three Fingers broad are prepar'd, the first being two Ells long, the second three, and the third three and a half. Three very streight Circumvolutions are to be made upon the Fracture; the Band is also to be carry'd up with Rollers, and stay'd above the Knee. The Application of the second Band is to be begun upon the Fracture with two Circumvolutions; it is to be brought down with Rollers, to pass under the Foot, afterward carry'd up again, and stay'd where it is terminated. The Leg is to be fill'd with a Bolster thicker at the bottom than at the top; and then are to be laid on the four longitudinal Bolsters, two Fingers broad, and as long as the Leg; to which are to be apply'd the Splints of a plyable and thin Wood: These are wrapt up with a simple Bolster, and strengthen'd with the third Band, which is apply'd indifferently either at the top or bottom, opposite to the former; so that it is carry'd up or else down in making Rollers, and stay'd at its end. The whole Contexture is to be encompass'd with large Paste-boards made round at the Ends, which are not to cross one another, {294} but must be streighter at the bottom than at the top, and are to be ty'd with three Ribbands or pieces of Tape, beginning at the middle; so that the Knots be ty'd on the outside. Afterward the Leg is to be put into the Scarves, and the Heel is to be supported with a Linnen-Roll, to which are fasten'd two Ribbands that are ty'd upon the Scarves: These Rolls are made with a small piece of Cloth, which is doubl'd, and roll'd up with the ends, in which is contain'd some Straw, and a little Stick in the middle, to consolidate 'em. The Foot is supported with a Paste-board or Wooden Sole, trimm'd with a Bolster, or small Quilt sow'd over it. Divers Strings are also fasten'd to the middle of the sides of the Sole or Pump, which are cross'd to be joyn'd to the Scarves; and another is fixt at the end of the Sole, which is ty'd to a Ribband that binds the middle of the Scarf. These Scarves are likewise fasten'd with three Ribbands, beginning with that in the middle, the Knots being without, and trimm'd with four Bolsters, that is to say, two on each side, to fill up the Cavities that are below the Knee, and above the Ankle. Lastly, the Leg is to be plac'd somewhat high, and a Cradle to be laid upon it, to keep off the Bed-Cloaths, the Scarves passing over the Knee and Foot. _The Dressing of Complicated Fractures_ Of the Arms, Legs, and Thighs is prepar'd with a Bandage having Eighteen Heads or Ends, in order to make which, a Linnen-Cloth is to {295} be taken of the length of the Part, and broad enough to cause it to be cross'd thereby: It is to be folded into three doubles, and cut in three places on each side, leaving the middle plain; so that eighteen Heads or small Bands are form'd, every one of which will be four fingers broad, the upper Heads being a little shorter than the lower. This Band of eighteen Heads is to be laid upon the Scarves, and a Bolster is to be apply'd to it four Fingers broad, as long as the Scarves. The Leg is laid upon this Bolster, and it hinders the corrupt Matter from falling on the Bandage. When the Wound hath been dress'd, the fracture is to be incontinently surrounded with one of the Heads, which ought to cross one another: Then after the Leg hath been bound with the first Heads, two Longitudinal Bolsters are to be apply'd to the side of it; and the other Heads are to be rais'd up, with all the rest of the Dressing, which hath been describ'd in the simple Fracture. * * * * * CHAP. XVIII. _Of the Fracture of the Bone of the Foot._ The Reduction of the Bone of the Foot is perform'd after the same manner as that of the Hand. {296} _The Dressing and Bandage_ Are made with a Band roll'd with two Heads, being three Ells long, and two Fingers broad: The Application of it is begun with a Circumvolution above the Ankles; it is pass'd on the Foot, and in like manner makes a Circumvolution round it: Afterward the same Band is cross'd over the _Metatarsus_, upon which are made some Folds in form of a _Rhombus_ or Diamond; as also on the Toes, and it is stay'd above the Ankle-Bone; or else it is carry'd up along the Leg, to be stay'd above the Knee. This Bandage serves for all Fractures of the Bones of the Foot, and is call'd the _Sandal_. * * * * * {297} A TREATISE OF THE OPERATIONS Which are perform'd in LUXATIONS. * * * * * CHAP. I. _Of the Luxation of the Nose._ The Bones of the Nose may be separated from that of the Fore-head by a Fall, or some violent Blow; and the Surgeon in order to set 'em, at first lays his Thumb upon the Root of the Nose, and then he introduceth a little Stick trimm'd with Cotton, into the Nostrils, and by the means thereof thrusts back the Bones into their place. {298} _The Dressing and Bandage_ Are the same with those that have been already describ'd in the Fracture of the Bones of the Nose. * * * * * CHAP. II. _Of the Luxation of the lower-Jaw._ The Jaw may be luxated either on both sides, or only on one. When the Dislocation happens on both sides, it hangs over the _Sternum_ or Breast-Bone, and the Spittle runs abundantly out of the Mouth: To reduce it, the Patient must sit down, and his Head is to be supported by a Servant; then the Operator or Surgeon having wrapt up his two Thumbs, puts 'em into the Mouth upon the Molar Teeth, his other Fingers lying under the Jaw, which is to be drawn down by raising it up, having before set two small Wooden Wedges upon the two Molar Teeth on both sides of the Jaw, lest the Surgeon's Fingers shou'd be hurt, as the Bone is returning to its place. If the Luxation be forward, a Band or Strap is to be put under the Chin, an Assistant having his Knees upon the Patient's Shoulders, where he is to draw the Strap upward, to facilitate the Extension; which the Surgeon makes with his Hands, at the same time thrusting the Bone back again into its place. {299} When the Jaw is luxated only on one side, the Chin stands a-cross, and the dislocated side is squash'd down, a small Cavity being perceiv'd in it, and a Rising on the other side; so that the Mouth cannot be shut close, but remains somewhat open, the lower Teeth appear farther out than the upper; and the Canine or Dog-Teeth lie under the Incisive. This Luxation is reduc'd by giving a blow with the Hand upon the luxated Bone, which is sufficient to cause it to re-enter its Natural Place. _The Dressing and Bandage_ Are altogether the same with those us'd in the Fracture of the Bones of the lower Jaw. * * * * * CHAP. III. _Of the Luxation of the _Clavicle_._ The _Clavicle_ is oftner loosen'd from the _Acromion_ than from the _Sternum_; when it hath left the former the Arm cannot be lifted up; the _Acromion_ makes a Prominence, and the Clavicle descends downward, a Cavity appearing in its place. To reduce this Luxation, the Patient is to be laid upon some Convex Body put between his Shoulders; both which are to be press'd backward, to raise up the Clavicle: Afterward he is to be set in a Chair, that his Arm may be drawn backward, whilst the {300} Surgeon is employ'd in pressing the Clavicle and _Acromion_, to join 'em together. _The Dressing and Bandage_ Are the same with those that we have already shewn, in treating of the Fracture of the Clavicle. * * * * * CHAP. IV. _Of the Luxation of the _Vertebra's. In the Luxation of the _Vertebra_'s of the Neck, the Head stands to one side, and the Face is swell'd and livid, with a difficulty of Respiration. To reduce this Dislocation, the Patient is to be set upon a low Seat, an Assistant leaning on his Shoulders, to keep his Body steady, whilst the Surgeon or Operator draws his Head upward, and turns it from one side to another: Then if the Accidents or Symptoms cease, the Cure is perform'd; so that Fomentations may be apply'd to the Part; and the Patient being laid in his Bed, must take care to avoid moving his Head. When the _Vertebra_'s of the Back or Loins are luxated on the inside, a sinking of the Bone is soon perceiv'd; whereupon the Patient being laid on his Belly, the Extension is to be made with Napkins pass'd under the Arm-Pits, and upon the _Os Ileum_, whilst the Surgeon with {301} a strong Extension makes some Efforts on the Spine, endeavouring to draw back the _Vertebra_. If that be not sufficient, an Incision is to be made upon the _Apophysis Spinosa_ of the _Vertebra_; so that after having laid open this Process of the Bone, it may be taken out with a Pair of _Forceps_. Then the Wound is to be dress'd with Pledgets, a Plaister, and a Napkin, which must not be bound too close, for fear of pushing back the Spine. When the _Vertebra_ is luxated on the outside, a Prominence appears; so that to reduce this Dislocation, the Extension is to be made as before, the Patient lying in like manner upon his Belly; but in order to push back the _Vertebra_, two little Sticks trimm'd with Linnen-Cloth are to be prepar'd, and laid along the two sides of the Spine of the _Vertebra_; yet these Sticks ought to be thick enough to remain more elevated than the _Apophysis Spinosa_; and a large wooden Roller is to be often roll'd upon 'em, which by its turning backward and forward, may thrust the _Vertebra_'s inward; so that when all the _Vertebra_'s are of an equal height, the Reduction is finish'd. If the _Vertebra_'s are luxated on the side, the same Extensions are to be made, and the Prominence is to be push'd, to re-establish the _Vertebra_ in its place. _The Dressing and Bandage._ The Dressing is prepar'd by laying two thin Plates of Lead on each side of the Spinous Process of the _Vertebra_, to maintain it in its Place, and a long Bolster over 'em. The {302} proper Bandage is the _Quadriga_, which hath been before describ'd, in treating of the Fractures of the Breast-Bone. * * * * * CHAP. V. _Of the Luxation of the _Coccyx_ or Rump-Bone._ If the _Coccyx_ be sunk on the inside, it is to be rais'd with the Fore-finger of the Right-hand put into the _Anus_; and if the Luxation be on the outside, it may be gently thrust back again. An Account of its proper Dressing and Bandage hath been already given in the Fracture of the _Coccyx_. * * * * * CHAP. VI. _Of the _Bunch_._ The _Bunch_ is nothing else but an exterior Luxation of the _Vertebra_'s, and for the Cure thereof, it wou'd be requisite to keep Emollients for a long time upon the _Vertebra_'s, to loosen the Ligaments, and to wear Iron-Bodice; which in compressing the _Vertebra_'s by little and little, might perhaps drive 'em back into their Natural Place. * * * * * {303} CHAP. VII. _Of the Luxation of the Ribs._ The Ribs are luxated either on the outside, or on the inside: If they be dislocated on the inside, a Cavity is perceiv'd near the _Vertebra_'s, the Patient drawing his Breath with Pain, and not being able to bend his Body. When the Luxation is on the outside, and happens in the upper Ribs, the Patient's Hands are to be hoisted upon the top of a Door, to raise up the Ribs, whilst the Surgeon presseth the Prominence of the Rib to restore it to its place. When the lower Ribs are luxated, the Patient must be oblig'd to stoop, laying his Hands upon his Knees, and the Prominence of the Bone is to be thrust back. If a Rib be luxated on the inside, an Incision is to be made to draw it out with the Fingers. _The Dressing and Bandage_ Are the same with those that are us'd in the Fracture of the Ribs. * * * * * {304} CHAP. VIII. _Of the Sinking of the _Xiphoides_, or Sword-like Cartilage_. To raise up the _Xiphoid_ Cartilage, it must be fomented before for some time with Oil of Turpentine, or other Fomentations, made with Aromaticks; then the Patient is to be laid upon his Back, with a Convex Body underneath, and the Shoulders, and Sides of the Breast are to be press'd, to lift up the Cartilage. When this Operation is not sufficient, dry Cupping-Glasses are usually apply'd, till the Part be elevated, and a strengthening Plaister is afterward laid upon it. * * * * * CHAP. IX. _Of the Luxation of the _Humerus_, or Arm-Bone_. The Head of the _Humerus_ generally falls under the Arm-Pit, so that the luxated Arm becomes longer than the other, the _Acromion_ appears pointed on the outside; the Elbow starts from the Ribs, and cannot be mov'd without great Pain. To reduce this Bone, the {305} Patient is to be set upon a low Seat, or else on the Ground, whilst some Person supports his Body with a Napkin: In the mean time the Surgeon is to lay hold on the upper-part of the _Humerus_, a Servant kneeling behind him, who is to hold the Patient's Arm above the Elbow, which is to pass between the Surgeon's Legs, and is to be drawn down by the Assistant as much as is possible, whilst the Surgeon in like manner draws the Arm, to remove the Head of the Bone out of the place where it was stopt; insomuch that the Bone sometimes makes a Noise in re-entring its Cavity. Or else the Patient's Arm may be laid upon the Shoulder of a taller Man than himself, who is strongly to draw the luxated Arm upon the Fore-part of his Breast; during which time, the Operator is to push the Head of the _Humerus_, to cause it to re-enter its Cavity. Otherwise the Patient may lie on the Ground, a Tennis-Ball being put under his Arm-Pit, which a Servant is to draw strongly with a Handkerchief pass'd under the Shoulder, whilst another Assistant stands behind the Patient, to thrust down the Shoulder with his Foot; at the same time the Surgeon sitting between the Patient's Legs, is to push strongly with his Heel the Ball that lies under the Arm-hole. Or else, a thick Battoon or Leaver may be laid on the Shoulders of two Men, after a Tennis-Ball hath been nail'd on the middle of it; otherwise a Bunch may be made therein, and cover'd with Linnen-Cloth; two Wooden Pins being also fixt on each side of the Ball: {306} Then the Patient's Arm-Pit is to be set between those two Pins, and upon the Ball, where he is to remain hanging, whilst his Arm is pull'd down by main force. The same thing may be done by laying the Patient's Arm-Pit upon a Door, or else upon the Round of a Ladder. _The Dressing and Bandage_ A little Ball of Linnen is to be laid under the Arm-Pit, and underneath a Bolster with four Heads, which are cross'd upon the Shoulder; as also a Bolster under the sound Arm-Hole, that it may not be gall'd by the Bandage _Spica_, the Nature of which we have shewn in treating of the Fracture of the Clavicle. * * * * * CHAP. X. _Of the Luxation of the Elbow._ When the Elbow is luxated on the inside, the Arm flies out, and the Hand is turn'd outward; but in the Luxation on the outside, the Arm is shortned: If the Luxation be Lateral, a Prominence appears in the Dislocated, and a Cavity in the opposite Part. To reduce the Internal Luxation, the _Humerus_ and _Cubitus_ are drawn, and at the same time the Surgeon bends the Elbow, by carrying {307} the Hand toward the Shoulder; or else a Tennis-Ball may be laid in the Fold of the Elbow, and the Arm drawn toward the Shoulder. For the External Luxation, the Extension is to be made, whilst the Surgeon thrusts back the Elbow into its place: Or else a round Stick may be taken, and trimm'd with Linnen-Cloth, with which the Bone is to be push'd back into its place during the Extension. This Stick may be also us'd in the reducing of the Internal Luxation. For the Lateral Luxations, the Extension may be made in like manner; the Surgeon at the same time thrusting back the Bone into its Natural Situation. _The Bandage_ Is made with a Band five Ells long, and two Fingers broad, roll'd with one Ball: The Application of it is begun with a Circumvolution at the lower part of the _Humerus_, it is pass'd over the Fold of the Arm; a Circumvolution is also form'd in the upper-part of the Elbow, and the Figure of KY in its Fold. Afterward the Rollers are continu'd upon the Elbow, and the KY's in the inside of the Arm, till the Elbow be entirely cover'd: The Band is likewise carry'd up to the top of the Arm with Rollers, and stay'd round about the Body. The Patient must be oblig'd to keep his Bed, or else his Arm may be put in a Scarf, after the same manner as in the Fracture of the Arm. * * * * * {308} CHAP. XI. _Of the Luxation of the Wrist._ If the Luxation be Internal, the Hand is turn'd back to the outside, so that for the Reduction thereof, it wou'd be requisite to cause the back of the Hand to be laid upon a Table, and the Extension to be made by drawing the Elbow and Hand, whilst the Surgeon takes care to press the Prominence. If the Luxation be External, the Hand is bended on the inside; so that to reduce it, the inside of the Hand is to be laid upon a Table, and the Surgeon is to press it after the Extension. If the Luxation be on the sides, the Hand is turn'd to one side; so that the Extension must be made, and the Hand turn'd on the side opposite to the Luxation. But the Fingers are usually drawn one after another, to the end that the Tendons may be set again in their Place. The eight Bones of the _Carpus_ may be in like manner dislocated both on the inside and without; and to set 'em right, the Hand is to be laid upon a Table, and the Extension to be made, so as to press the Protuberances on the inside, if the Luxation be internal, and on the outside if it be external. {309} _The Bandage_ Is prepar'd with a Band six Ells long, and two Fingers broad; so that three Circumvolutions may be made upon the Luxation; as also divers Rollers in passing thro' the inside of the Hand between the Thumb and the Forefinger, and in forming the Figure of KY upon the Thumb, after having made many Rollers upon the Wrist. Two Pieces of Paste-board are also to be laid on the sides of the Wrist, which are bound with the same Band in making Rollers; and the Hand is to be trimm'd with a Linnen-Ball, to keep the Fingers in their mean Situation. Then the Band is to be pass'd above, to strengthen it, and carry'd up with Rollers along the whole length of the Elbow, to be stay'd below the same Elbow. * * * * * CHAP. XII. _Of the Luxation of the Fingers._ If the Fingers be luxated, it is necessary to make an Extension to reduce 'em, and afterward to use the following _Bandage._ If the Luxation be in the first Articulation or Joint, the Bandage _Spica_ is to be apply'd, being made of a Band roll'd with one Head, an {310} Ell long, and an Inch broad: It is begun with Circumvolutions round about the Wrist, and brought over the Luxation in passing between the Fingers. These Circumvolutions are also continu'd to form a _Spica_ upon the Luxation; and the Band is stay'd at the Wrist. If all the first _Phalanges_ were dislocated, it wou'd be requisite to make as many upon every _Phalanx_, and with the same Band: This sort of Bandage is call'd the _Demi-Gantlet_. * * * * * CHAP. XIII. _Of the Luxation of the Thigh._ The Luxation which most commonly happens in this Part, is the Internal; so that a Protuberance appears on the Hole of the _Os Pubis_; the indispos'd Leg is longer than the other, and the Knee and Foot turn outward; neither can the Thigh be any longer bended, nor drawn near the other. If the Luxation be External, the Leg becomes shorter than the other, the Knee and Foot turning inward, and the Heel to the outside. When the Luxation is on the fore-part, a Tumour ariseth in the Groin, so that the Patient cannot draw this Thigh toward the other, nor bend the Leg; his Body resting only upon the Heel. {311} If the Luxation be Posterior, a Tumour is felt in the Buttocks with great Pain, and the Legg is shorter than it ought to be: There also appears a sinking in the Groin, the Leg is lifted off from the Ground, and the hurt Person is apt to fall backward. To reduce the Internal Luxation, the Patient is to be laid with his Back upon a Table, to which is fixt a thick Wooden Pin, about a Foot long, which is to be set between his Thighs, to detain his Body when his Legs are drawn down; then a Strap is to be pass'd above the joynt of the Thigh, to draw the _Ischion_ upward; and the Thigh is to be drawn down with another Strap fasten'd above the Knee: In the mean while the Surgeon thrusts the Thigh upward, to cause it to re-enter its Cavity, the Straps being somewhat loosen'd in the time of the Reduction to facilitate the Operation. To reduce the External Luxation, the Patient is to be laid upon his Belly; and the drawing to be perform'd after the same manner as we have even now shewn, whilst the Thigh is thrust from the outside inward, to cause the bone to re-enter its Cavity. In reducing the Anterior Luxation, the hurt Person is to be laid upon the side opposite to the Luxation, and Extensions are to be made, by drawing both upward and down-ward, as before: Then the Head of the Bone is to be forc'd, by the means of a Ball thrust strongly with the Knee, in drawing the luxated leg toward the other. {312} The Posterior Luxation is thus reduc'd; The Patient being laid upon his Belly, the double Extension is to be made, and his Knee drawn outward, to set the Bone in its place. After the Operation hath been perform'd, a Bolster is to be apply'd, steept in Spirituous Medicaments; and the Bandage call'd _Spica_, of which we have given an Account in treating of the Luxation of the Shoulder. * * * * * CHAP. XIV. _Of the Luxation of the Knee._ When the _Tibia_ is luxated behind, its Prominences are in the Cavity of the Ham, and the Leg flies off, or is bended. If the same _Tibia_ be dislocated on the side, a kind of Tumour appears in the luxated side, and a Sinking in the opposite. But if the _Condylus_ of the _Tibia_ remains in the inside, the Leg turns outward; and if it be in the outside, it turns inward. The Posterior Luxation is reduc'd by obliging the Patient to lie upon his Belly, whilst the Surgeon during the Extensions bends the Leg, in drawing the Heel toward the top of the Thigh. If the _Tibia_ be luxated on the side, the usual Extensions are to be made, and the Bone is to be push'd with the Knee. {313} If the Luxation were in the fore-part, it wou'd be requisite to lay the Patient upon his Back, to make the Extensions, by drawing the Thigh and Leg; and to press the protuberant Parts. _The Bandage_ Is prepar'd with a Band three Ells long, and two Fingers broad, roll'd with two Balls: A Circumvolution being at first made above the Knee, the Figure KY is form'd underneath, and a Circumvolution above it; then the Band is carry'd up again over the Knee, in making Rollers and KY's underneath, till the Knee be entirely cover'd. * * * * * CHAP. XV. _Of the Luxation of the _Patella_ or Knee-Pan._ The Knee-Pan is luxated by starting upward; and to reduce it, the Patient's Leg is to be held streight, whilst it is thrust back into its place with the Hands. Then he must be oblig'd to keep his Bed; and the same Bandage is to be apply'd with that which hath been describ'd for the Luxation of the Knee. If the _Perone_ or _Fibula_ be remov'd from the _Tibia_, the sides of the Foot are to be press'd, to draw it back again; and it may be kept close {314} with the Bandage which is appropriated to the Fractures of the _Tarsus_. The _Astragalus_ may be also luxated in the fore-part; so that the Operator ought to thrust it back into its place, and to make use of the Bandage which we have prepar'd for the Fracture of the Foot. The _Calcaneum_ sometimes flies off from the _Astragalus_ both in the inside and without; and the Bones of the _Tarsus_, _Metatarsus_, and Toes are likewise apt to be luxated. But a little Circumspection is only requisite to reduce all these Dislocations. * * * * * {315} A TREATISE OF _Medicinal Compositions_ Necessary for a SURGEON. * * * * * CHAP. I. _Of Balsams._ * * * * * _The Balsam of _Arcæus_._ Take two Pounds of the Suet of a He-Goat, _Venice_ Turpentine and Gum _Elemi_, a Pound and a half of each; and of Hogs-Lard one Pound. After the Gum _Elemi_, being cut into small Pieces, hath been melted over a very gentle Fire, add to it the Turpentine, Goats-Suet, and {316} Swines-Grease; and when all these Ingredients are well dissolv'd, strain the Liquor thro' a new Linnen-Cloth, to separate the Scum and Dregs from it; then let the whole Mass cool, and the Balsam is made. This Balsam serves to incarnate and consolidate all sorts of Wounds and Ulcers: It is likewise us'd in Fractures and Dislocations of the Bones; as also to cure the Contusions and Wounds of the Nerves. _The Balsam of _Spain_._ Take pure Wheat, the Roots of Valerian and _Carduus Benedictus_, of each one Ounce, and beat 'em well in a Mortar with a Pint of White-Wine; strain the whole Composition into an Earthen Vessel Leaded, having a narrow Mouth; stop up the Vessel, and set it upon hot Embers during twenty four Hours: Then add six Ounces, of St. _John_'s Wort; set the whole Mass in _Balneo Mariæ_, till the Wine be consum'd and let it be strain'd and squeez'd. Afterward add two Ounces of Frankincense well pulveriz'd, with eight Ounces of _Venice_ Turpentine, mixing 'em together over a gentle Fire, and the Balsam will be made. This is the Balsam which was always us'd by _Hieronymus Fabritius ab Aguapendente_, a noted _Italian_ Surgeon, and is excellent for all kinds of Wounds, even for the Nervous, which (as it is avouch'd by some Persons) may be cur'd by it within the space of twenty four Hours. But the Wound must be at first wash'd with good White-Wine cold, and afterward anointed {317} with this Balsam well heated. If the Wound be deep, it may be syringed with the same Balsam very hot, and the sides of it anointed when drawn together. Then a Bolster steep'd in the Balsam is to be apply'd to the Part, and upon that another Bolster soakt in the Lees of Wine; as also over this last another drie Bolster. _The Green Balsam._ Take Linseed-Oil and that of Olives, of each one Pint; one Ounce of Oil of Bays; two Ounces of _Venice_ Turpentine, half an Ounce of the destill'd Oil of Juniper-Berries, three Drams of Verdegrease, two Drams of Sucotrin Aloes, two Drams and a half of White Vitriol, and one of the Oil of Cloves. Having made choice of the best Olive and Linseed-Oil well purify'd and mingl'd together in a Skillet or Pan over a very gentle Fire, let the Turpentine and Oil of Bays be incorporated in it; then having taken off the Pan from the Fire, and left the Liquor to be well cool'd, let it be intermixt by little and little with the Verdegrease, the White Vitriol, and the Sucotrin Aloes beaten to fine Powder: Afterward the destill'd Oils of Cloves and Juniper-Berries being added, and the whole Composition well mingl'd together, the Balsam will be entirely compounded according to Art. This is the Balsam that hath been so much talkt of at _Paris_, and which many Quack-Salvers, pretending to the Art of Physick and Surgery, keep as a great Secret. Indeed it is very good for all sorts of Wounds, whether they {318} be made by the Sword, or other Iron Weapons, or by Gun-shot. But it wou'd be requisite at first to wash the Wound with warm Wine, then to anoint it with this Balsam very hot, and to apply Bolsters that have been steept in it, as also a large Bolster over the other, dipt in some Styptick Liquor. This Balsam mundifies, incarnates, and cicatrizes Wounds; being likewise good against the Bitings of venomous Beasts, and fistulous and malignant Ulcers. __Samaritan_ Balsam._ Take an equal quantity of common Oil and good Wine; boil 'em together in a glaz'd Earthen Vessel, till the Wine be wholly consum'd, and the Balsam will be made. I have produc'd this Balsam in particular, by reason of its simplicity, and in regard that it may be readily prepar'd at all times. It serves to mundifie and consolidate simple Wounds more especially those that are recent. * * * * * {319} CHAP. II. _Of Ointments._ * * * * * __Unguentum Althææ_._ Take of the Roots of _Althæa_ or Marsh-Mallows, six Ounces, the Seeds of Line, and Fenugreek, and Squills, of each four Ounces; of yellow Wax one Pound; Colophony and Rosin, of each one Pound; _Venice_ Turpentine, _Galbanum_, and Gum _Hederæ_ pulveriz'd, two Ounces of each. The Marsh-Mallow-Roots being newly gather'd, are to be well wash'd and slic'd, as well as the Squills. After they have been put into a Copper-Pan or Skillet, tinn'd over on the inside, together with the Seeds of Line and Fenugreek, and a Gallon of fair Water pour'd upon 'em, the whole Mass is to be macerated during twenty four Hours, over a very gentle Fire, stirring the Ingredients from time to time with a Wooden _Spatula_: Thus they are to be boil'd slowly, often reiterating the stirring, till the Mucilages are sufficiently thicken'd; then, after having well squeez'd and strain'd 'em thro' a strong and very close Cloth, and mingl'd 'em with the prepar'd Oil, they are to be boil'd together again over a very gentle Fire, till the Superfluous Moisture of the Mucilages be wholly {320} consum'd: Afterward having strain'd the Oil again, the yellow Wax, Colophony, and Rosin cut into small pieces, are to be melted in it; and if any Dregs appear at the bottom of the Pan, when the whole Mass is dissolv'd, it is to be strain'd a-new, or at least the pure Liquor must be separated from the gross or impure by Inclination, whilst it is as yet very hot: The Ointment is to be stirr'd about with a Wooden Pestle; and when it begins to grow thick, you may add the Turpentine, the _Galbanum_ purify'd and thicken'd, and the Gum _Hederæ_ beaten to fine Powder, all which Ingredients were before incorporated together. Then the Ointment is to be continually stirr'd, till it be altogether grown cold. This Ointment serves to moisten, mollifie, and heat gently; it also allayes the Pains of the Side, and softens Tumours, particularly the _Parotides_. It may be us'd either alone, or with other Ointments or Oils. _The mundificative Ointment of Smallage._ Take three handfuls of Smallage-Leaves; with Ground-Ivy, great Wormwood, great Centory, Germander, Sage, St. _John_'s-Wort, Plantain, Milfoil or Yarrow, Perewinkle, the greater Comfrey, the lesser Comfrey, Betony, Honey-suckle, Fluellin, Vervein, Knot-Grass, Adders-Tongue, and Burnet, of every one of these Plants two handfuls; a Gallon of common Oil, white Pitch, Mutton-Suet, yellow Wax, and Turpentine, of each two Pounds. {321} Bruise all these Herbs in a Marble-Mortar; let the Wax, white Pitch, and Mutton-Suet cut into pieces, as also the Turpentine be melted in the Oil, in a Copper-Pan lin'd with Tin, over a moderate Fire; put the bruis'd Herbs in it, and cause the whole Mass to simmer together very slowly, stirring it about from time to time with a Wooden _Spatula_. As soon as it shall be perceiv'd that the Oil of the Herbs is almost quite consum'd, the whole Composition is to be strain'd, and strongly squeez'd. Then after having let the Ointment cool, to draw off all the Dregs and Moisture, it is to be dissolv'd over a very gentle Fire; and after having left it a little while to cool again and thicken, you may add thereto Myrrh, Aloes, _Florence_ Orris, and round Birth-Wort pulveriz'd very fine. When all these Ingredients are by this means well incorporated, the Ointment will be brought to perfection. This Ointment is of singular Use to cleanse Ulcers; as also to mundifie, cicatrize, and consolidate all sorts of Wounds. _The black or suppurative Ointment._ Take a Quart of common Oil, white and yellow Wax, Mutton-Suet that lies near the Kidneys, pure Rosin, Ship-Pitch, _Venice_ Turpentine, of each half a Pound; and of Mastick beaten to fine Powder, two Ounces; let all that is capable of being dissolv'd, be liquify'd in the Oil; and add the Powder of Mastick to make an Ointment. {322} This Ointment searches and opens all sorts of Impostumes, as well as Carbuncles, and Pestilential and Venereal Bubo's. The use of the same Ointment is also to be continu'd after the opening of the Abcesses, till their perfect Cure be compleated. __Unguentum Rosatum_._ Take Bore's-Grease well purify'd, and often wash'd, and Red Roses newly pickt, of each four Pounds, with the like quantity of White Roses. The thin Membrane or Skin which lies upon the Bores-Grease, being taken away, it is to be cut into small pieces, well wash'd in fair Water, and melted in a glaz'd Earthen-Pot over a very gentle Fire; the first Grease that is dissolv'd is to be strain'd thro' a Cloth, well wash'd, and mixt with the same quantity of thick Rose-Buds well bruis'd. Then the whole Mass is to be put into a glaz'd Earthen-Pot with a narrow Mouth; the Pot is to be well stopt, and set during six Hours in Water, which is between luke-warm and boiling hot. Afterward it is to be boil'd an Hour, strain'd and strongly squeez'd. In the mean while four Pounds of White Roses newly blown are to be taken, well bruis'd, and mingl'd with the former Composition, the Pot being cover'd, which is likewise set for the space of six Hours in Water, between luke-warm and boiling hot: Then the Liquor is to be strain'd and strongly squeez'd. Lastly, after the Ointment hath been cool'd, and separated from its _Fæces_ or Dregs, it may be kept for use. {323} If it be desir'd to give a Rose-Colour to this Ointment, it wou'd be requisite a quarter of an Hour before it be strain'd the last time, to throw into it two or three Ounces of _Orcanet_, which is to be stirr'd into the Ointment. If it be thought fit to retain the White Colour, and to produce the smell of Roses, it may be done with Damask-Roses without _Orcanet_. If you are desirous to give it the Consistence of a Liniment, you may add Oil of sweet Almonds to the quantity of a sixth part of its weight. This Ointment is a very good Remedy against all manner of external Inflammations, particularly against _Phlegmons_, _Erysipelas's_, and Tetters; as also against the Head-ach and Hæmorrhoids or Piles. __Unguentum Album, aut de Cerussa_._ Take three Pints of Oil of Roses, nine Ounces of white Wax, one Pound of _Venice_ Ceruse or white Lead, and a Dram and a half of Camphire. The Ceruse being pulveriz'd by rubbing the pieces upon the Cloath of a Hair-Sieve turn'd upside-down; the Powder is to be receiv'd on a Sheet of Paper laid underneath, and to be often wash'd with Water in a great Earthen-Pan, stirring it about with a Wooden _Spatula_, and pouring off the Water by Inclination as soon as the Powder is sunk to the Bottom. When the Water of these Washings grows insipid, the last Lotion is to be made with Rose-Water, leaving it for the space of five or six Hours, which being expir'd, it is to be pour'd off by Inclination, and {324} the Ceruse must be dry'd in the Shade, cover'd with Paper. Then the broken Wax and prepar'd Oil is to put into a glaz'd Earthen-Pot, and the Pot into the boiling Bath. As soon as the Wax is melted, the Pot may be taken out of the Bath, and the dissolv'd Liquor stirr'd with a Wooden Pestle till it begins to grow thick. Afterward the pulveriz'd Ceruse is to be infus'd, and the Ointment stirr'd about till it be almost cold. If you shall think fit to add Camphire, let it be dissolv'd in a little Oil, and incorporated with the Ointment when it is cold. The Whites of Eggs may be also well mixt with the Ointment, by stirring it about, to make an exact union of the several Ingredients. This Ointment is good for Burns, _Erysipelas's_, the Itch, and many Distempers of the Skin; it allayes the Itchings and intemperature of Ulcers; it dissipates the Chafings and Redness that happen in the Bodies of Infants; It is of great efficacy in the healing of Contusions, and it serves to consolidate and cool light Wounds. __Unguentum Ægyptiacum_._ Take eleven Ounces of Verdegrease, fourteen Ounces of strong Vinegar, and twenty eight Ounces of good Honey. Let the Verdegrease be put into a Copper-Pan or Skillet over a very gentle Fire; then bruise it with a Wooden Pestle; work it well in the Vinegar, and strain the whole thro' a Hair-Sieve. If a little Verdegrease remains on the Sieve, it is to be put again into the {325} Skillet bruis'd and beaten small therein, as before, with a Portion of the same Vinegar, straining it thro' the Sieve, till the unprofitable drossy parts of the Copper be only left. Afterward this Liquor is to be boil'd over a gentle Fire, with the Honey, stirring it about from time to time till it hath acquir'd the Consistence of a softish Ointment, and a very red Colour. This Ointment consumes putrify'd Flesh, and the Superfluities of Ulcers and Wounds. __Unguentum Basilicon_, or Royal Ointment_. Take yellow Wax, Mutton-Suet, Rosin, Ship-Pitch, and _Venice_ Turpentine, one Pound of each; with five Pints of common Oil. Cut the Suet, Rosin, and black Pitch into small Pieces, and let 'em be melted together, with the Oil, in a Copper-Pan over a very moderate Fire; then after having strain'd the Liquor thro' a thick Cloth, let it be incorporated with the Turpentine, and the Ointment will be made. It promotes Suppuration, and cicatrizes Wounds when the purulent Matter is drawn forth. It is often laid alone upon the Bolsters, and sometimes mixt with the Yolks of Eggs, Turpentine, and other Ointments, or with Oils and Plaisters. {326} _A cooling Cerate._ Take a Pint of Oil of Roses, and three Ounces of white Wax. Let the whole Composition be put into a glaz'd Earthen-Pot, and the Pot set in _Balneo Mariæ_, till the Wax be well dissolv'd in the Oil: Then take the Vessel out of the Bath, and stir the Ointment with a Wooden Pestle till it be cool'd; add two Ounces of Water, and stir it about with the Pestle till it be imbib'd by the Cerate; let as much more Water be infus'd, and again the same quantity, till the Cerate becomes very white, and hath been well soakt with fresh Water. Afterward all the Water is to be pour'd off by Inclination, and separated as much as is possible from the Cerate, which may then be kept for use; but some Surgeons cause an Ounce of Vinegar to be mingl'd with it. This Cerate is usually laid outwardly upon all Parts that stand in need of cooling, and asswages the Pains of the Hæmorrhoids or Piles. It is also good for Chaps, sore Nipples, and other ill Accidents that happen in the Breast; and is us'd for Burns either alone, or mixt with other Ointments. Whensoever it is necessary to apply Desiccatives and Astringents to any Part, this Cerate may be mingl'd with _Unguentum de Cerussa_. {327} _An Ointment for Burns._ Take a Pound of Bores-Grease, two Pints of White-Wine, the Leaves of the greater Sage, Ground- and Wall-Ivy, Sweet Marjoram, or the Greater House-Leek, of each two handfuls. Let the whole Mass be boil'd over a gentle Fire, and having afterward strain'd and squeez'd it, let the Ointment so made be kept for use. * * * * * CHAP. III. _Of Plaisters._ * * * * * _The Plaister of _Diapalma_._ Take three Pounds of prepar'd Litharge of Gold, three Pints of common Oil, two Pounds of Hogs-Lard, a Quart of the Decoction of Palm-Tree or Oak-Tops; four Ounces of Vitriol calcin'd till it become red, and steept in the said Decoction. Having bruis'd or cut very small two handfuls of Palm-Tree or Oak-Tops, let 'em be boil'd slowly in three Quarts of Water till about half be consum'd; and after the whole Mass hath been well squeez'd, the strain'd Decoction is to be preserv'd. In the mean time the Litharge is to be {328} pounded in a great Brass Mortar, and diluted with two or three Quarts of clear Water; but it will be requisite readily to pour out into another Vessel the muddy Water which is impregnated with the more subtil part of the Litharge, whilst the thicker remains at the bottom of the Mortar; whereupon this part of the Litharge will sink to the bottom of the Water, and the Litharge remaining in the Mortar is to be pounded again. Then having diluted it in the Water of the first Lotion, or in some other fresh Water, the muddy Liquor is to be pour'd by Inclination upon the subtil Litharge that remain'd in the bottom of the Vessel: Afterward you may continue to pound the Litharge, to bruise it in the Water, to pour it off by Inclination, and to let the Powder settle, till there be left only at the bottom a certain impure part of the Litharge, capable of being pulveriz'd, and rais'd amidst the Water. As soon as the Lotions are well settl'd, and care hath been taken to separate by Inclination the Water which swims over the Powder of Litharge; this Powder is to be dry'd, and having weigh'd out the appointed Quantity, it is to be put as yet cold into a Copper-Pan lin'd with Tin, and stirr'd about to mingle it with the Oil, Lard, and Decoction of Palm-Tree-Tops. When these Ingredients have been well incorporated together, a good Charcoal Fire must be kindl'd in a Furnace, over which they are to be boil'd, stirring 'em continually with a great Wooden _Spatula_, and constantly maintaining an equal Degree of Heat during the whole time of their boiling. At last you may add {329} the rubify'd Vitriol dissolv'd in a Portion of the Liquor that hath been reserv'd, if you wou'd have the Plaister tinctur'd with a red Colour; or else white Vitriol melted in the same Decoction, if it shall be thought fit to retain the Whiteness of the Plaister, which may be form'd into Rolls, and wrapt up with Paper. This Plaister is us'd for the cure of Wounds, Ulcers, Tumours, Burns, Contusions, Fractures, and Chilblains, and is also laid upon the Cauteries. If you mingle with it the third or fourth part of its weight of some convenient Oil, it will attain to the Consistence of a Cerate; and this is that which is call'd _Dissolved Diapalma_ or _Cerate of Diapalma_. _The Plaister of simple _Diachylum_._ Take of Marsh-Mallow-Roots peel'd, three Drams; the Seeds of Line and Fenugreek, of each four Ounces; three Quarts of Spring-Water; two Quarts of common Oil, and two Pounds of Litharge of Gold. Let the Mucilages of Marsh-Mallow-Roots, and of the Seeds of Line and Fenugreek be taken, as hath been shewn in the making of _Unguentum Althææ_, and let the Litharge be prepar'd after the same manner as for the Plaister of _Diapalma_. Having at first well mixt the Oil with the Litharge in a large Copper-Vessel or Pan, Tinn'd on the inside, being wide at the top, and tapering like a Cone toward the bottom, as also having afterward added and well incorporated the Mucilages, a moderate {330} Charcoal Fire is to be kindl'd in a Furnace, upon which the Vessel is to be set, and the whole Mass is to be stirr'd about incessantly with a Wooden _Spatula_; and as fast as is possible. A gentle Fire is to be maintain'd, and the Boiling and Agitation to be continu'd, till it be perceiv'd that the Plaister begins to sink in the Pan; then the Heat of the Fire must be diminish'd one half at the least; and it will be requisite only to cause an Evaporation by little and little, of the Superfluous Moisture that might remain in the plaister, which being consum'd, it will be sufficiently boil'd, having attain'd to its due Consistence and Whiteness. This Plaister softens and dissolves hard Swellings, and even the Scirrhous Tumours of the Liver and Bowels; such are the Scrophulous or King's-Evil Tumours, the old remains of Abcesses, _&c._ _The Plaister of _Andreas Crucius_._ Take two Ounces of Rosin; four Ounces of Gum _Elemi_, _Venice_ Turpentine and Oil of Bays, of each two Ounces. After having beat in pieces the Rosin and Gum _Elemi_, they are to be melted together over a very gentle Fire, and then may be added the Turpentine and Oil of Bays. When the whole Mass hath been by this means well incorporated, it must be strain'd thro' a Cloth, to separate it from the Dregs. The Plaister being afterward cool'd, is to be made up in Rolls, and kept for use. {331} This Plaister is proper for Wounds of the Breast: It also mundifies and consolidates all sorts of Wounds and Ulcers, dissipates Contusions, strengthens the Parts in Fractures and Dislocations, and causeth the Serous Humours to pass away by Transpiration. __Emplastrum Divinum_._ Take of Litharge of Gold prepar'd, one Pound and an half; three Pints of common Oil; one Quart of Spring-Water; six Ounces of prepar'd Load-Stone; Gum _Ammoniack_, _Galbanum_, _Opoponax_, and _Bdellium_, of each three Ounces; Myrrh, _Olibanum_, Mastick, Verdegrease, and round Birth-Wort, of every one of these an Ounce and an half; eight Ounces of Yellow Wax, and four Ounces of Turpentine. Let the Gum _Ammoniack_, _Galbanum_, _Bdellium_, and _Opopanax_ be dissolv'd in Vinegar, in a little Earthen Pipkin; strain 'em thro' a course Cloth, and let 'em be thicken'd by Evaporation, according to the Method before observ'd in other Plaisters: Then prepare the Load-Stone upon a Porphyry or Marble-Stone, and take care to bruise separately, the _Olibanum_, the Mastick, the Myrrh, the round Birth-Wort, and the Verdegrease, which is to be kept to be added at last. In the mean while, having incorporated cold the Oil with the Litharge, and mingl'd the Water with 'em, they are to be boil'd together over a very good Fire, stirring 'em incessantly, till the whole Composition hath aquir'd the Consistence of a somewhat solid {332} Plaister, in which is to be dissolv'd the yellow Wax cut into small pieces. Afterward having taken off the Pan from the Fire, and left the Ingredients to be half cool'd, intermix the Gums, which have been already thicken'd and incorporated with the Turpentine; then the Load-Stone mingl'd with the Birth-Wort, Myrrh, Mastick, and _Olibanum_; and last of all the Verdegrease. Thus when all these Ingredients are well stirr'd and mixt together, the Plaister will be entirely compounded; so that it may be made up into Rolls, and preserv'd to be us'd upon necessary Occasions. This Plaister is efficacious in curing of all kinds of Wounds, Ulcers, Tumours, and Contusions; for it mollifies, digestes, and brings to Suppuration such Matter as ought to be carry'd off this way. It also mundifies, cicatrizes, and entirely consolidates Wounds, _&c._ * * * * * CHAP. IV. _Of Cataplasms or Pultisses._ Cataplasms are usually prepar'd to asswage Pain; as also to dissolve and dissipate recent Tumours, and are made thus: Take four Ounces and a half of white Bread, one Pint of new Milk, three Yolks of Eggs, one Ounce of Oil of Roses, one Dram of Saffron, and two Drams of the Extract of _Opium_. {333} The Crum is to be taken out of the inside of a white Loaf newly drawn out of the Oven, and to be boil'd with the Milk in a Skillet over a little Fire, stirring it from time to time with a _Spatula_, till it be reduc'd to a thick Pap. After having taken the Vessel off from the Fire, the three Yolks of Eggs beaten are to be put into it, and the Dram of Saffron pulveriz'd; to these Ingredients may be added two Drams of the Extract of _Opium_ somewhat liquid, if the Pain be great. _Here is another Cataplasm proper to mollifie and to bring to Suppuration when it is necessary._ Take White-Lilly-Roots, and Marsh-Mallow-Roots, of each four Ounces; the Leaves of common Mallows, Marsh-Mallows, Groundsel, Violet-Plants, Brank-Ursin, of every one of these Herbs one handful; the Meal of Line, Fenugreek, and Oil of Lillies, of each three Ounces. The Roots when wash'd and slic'd, are to be boil'd in Water, and the Leaves being added some time after, the Boiling is to be continu'd till the whole Mass becomes perfectly tender and soft; at which time having strain'd the Decoction, beat the remaining gross Substance in a Stone-Mortar, with a Wooden Pestle, and pass the Pulp thro' a Hair-Sieve turn'd upside-down: Then let the Decoction and Pulp so strain'd be put into a Skillet, and having intermixt the Meal of Line, Fenugreek, {334} and Oil of Lillies; let 'em be boil'd together over a gentle Fire, stirring about the Ingredients from time to time, till they be all sufficiently thicken'd. These two Cataplasms may serve as a Model for the making of many others. * * * * * CHAP. V. _Of Oils._ Oils are made either by Infusion or Expression. _Simple Oil of Roses made by Infusion._ Take two Pounds of Roses newly gather'd, and bruis'd in a Mortar; half a Pint of the Juice of Roses, and five Pints of common Oil: Let the whole Composition be put into a Earthen-Vessel, Leaded and well stopt, and then let it be expos'd to the Sun during forty Days. Afterward let it be boil'd in _Balneo Mariæ_; and having strain'd and squeez'd the Roses, let the Oil be kept for use. _Compound Oil of Roses made by Infusion._ Take a Pound of Red Roses newly gather'd, and pound 'em in a Mortar; as also four Ounces of the Juice of Red Roses, and two Quarts of common Oil. Let the whole Composition be put into an Earthen-Vessel Leaded, the Mouth {335} of which is narrow, and well stopt; and then having expos'd it to the Sun during four Days, let it be set in _Balneo Mariæ_ for an Hour, and then strain'd and squeez'd. Afterward let this Liquor be put into the same Vessel, adding to it the Juice of Roses, and Roses themselves, in the same quantity as before: Let the Vessel be stopt; let the Maceration, Boiling, Straining, and Expression be made in like manner as before; and let the same Operation be once more re-iterated: Then let your Oil be depurated, and preserv'd for use. These Oils qualifie and disperse Defluctions of Humours, suppress Inflammations, mitigate the Head-ach and _Deliriums_, and provoke to sleep. They must be warm'd before the Parts are anointed with 'em, and they may be given inwardly against the Bloody-flux and Worms, the Dose being from half an Ounce to a whole Ounce. The Parts are also anointed with 'em in Fractures and Dislocations of the Bones, and _Oxyrodins_ are made of 'em with an equal quantity of Vinegar of Roses. _Oil of Sweet Almonds made by Expression._ Take new Almonds that are fat and very dry, without their Shells, and having shaken 'em in a somewhat thick Sieve, to cause the Dust to fall off; let 'em be put into hot Water till their Skins become tender, so that they may be separated by squeezing 'em with the Fingers: Afterward having taken off the Skin, they must be wip'd with a white Linnen-Cloth, and spread upon it to be dry'd: Then they are {336} to be put into a Stone-Mortar, and pounded with a Wooden-Pestle, till the Paste grows very thin, and begins to give Oil: This Paste is to be put into a little Linnen-Bag, new and strong, the Mouth of which hath been well ty'd; and the Bag is to be plac'd between two Platines of Tin, or of Wood lin'd on the inside with a Leaf of Tin, squeezing the whole Mass gently at first; but afterward very strongly, and leaving it for a long while in the Press, that the Oil may have time to run out. This Oil mitigates the Nephritick Colicks, remedies the Retention of Urine, facilitates Child-birth, allayes the After-Pains in Women after their delivery, and the Gripes in young Infants: It is taken inwardly fasting from half an Ounce to two Ounces; and it is us'd in Liniments to asswage and mollifie. The Oils of common Wall-Nuts and Small-Nuts, may be also prepar'd after the same manner as that of Sweet-Almonds. _The Oil of Bayes._ Take as much as you please of Laurel or Bay-Berries, well cleans'd, perfectly ripe, and soundly bruis'd; let 'em be put into a Kettle, and boil'd with a sufficient quantity of Water during half an Hour; then strain and squeeze 'em strongly; let the Liquor cool, and scum off the Fat that swims upon the Water: Afterward pound the remaining Substance in a Mortar, and cause it to be boil'd again for half an Hour, with some of the first Water which was left, adding a little fresh; then strain and squeez it, {337} as before, and take off the Oil that swims on the Top. But the first Oil is better than the second, and therefore ought to be kept separately. The Oils of Berries of Mastick, Myrtle, and other oleaginous Plants, may be extracted after the same manner. The Oil of Bayes mollifies, attenuates, and is opening and discussive: It is very good against the Palsie, and the Shiverings or cold Fits of a feaver or Ague in anointing the Back; as also against Scabs, Tetters, _&c._ _The Oil of Eggs by Expression._ Take newly laid Eggs, and let 'em be harden'd in Water; then separate the Yolks, and put 'em into a Frying-pan over a gentle Coal-fire, stirring 'em about from time to time, and at last without discontinuing, till they grow reddish, and begin to yield their Oil: Then they are to be sprinkl'd with Spirit of Wine, and pour'd very hot into a little Linnen-Bag, which is to be ty'd, and set in a Press between two heated Platines; so that the Oil may be squeez'd out as readily as is possible. This Oil mitigates the Pains of the Ears and Hæmorrhoids, cures Scabs and Ring-Worms or Tetters; as also Chaps and Clefts in the Breast, Hands, Feet, and Fundament; and is made use of in Burns, _&c._ * * * * * {338} CHAP. VI. _Of _Collyrium_'s._ _Collyrium's_ are Medicines prepar'd for the Diseases of the Eyes: The following is that of _Lanfrancus_. Take a Pint of White-Wine, three Pints of Plantain-Water, three Pounds of Roses, two Drams of _Orpiment_, one Dram of Verdegrease; Myrrh and Aloes, of each two Scruples. The _Orpiment_, Verdegrease, Myrrh, and Aloes are to be beaten to a fine Powder before they are intermixt with the Liquors. This _Collyrium_ is not only good for the Eyes, but is also of use to make Injections into the Privy-Parts of Men and Women; but before the Injections are made, it ought to be sweeten'd with three or four times the quantity in weight of Rose, Plantain, or Morel-Water. _A dry _Collyrium_._ Take two Drams of Sugar-candy; prepar'd Tutty, Lizard's-Dung, of each one Dram; White Vitriol, Sucotrin Aloes, and _Sal Saturni_, of each half a Dram. Let the whole Composition be reduc'd to a very fine Powder, and mixt together: Two or three Grains of this Powder may be blown at {339} once into the Eye with a small Quill, Pipe of Straw, or Reed, as long as it is necessary; and the same Powder may also be steept in Ophthalmick Waters, to make a liquid _Collyrium_. _A Blue _Collyrium_._ Take a Pint of Water in which unslackt Lime has been quench'd, and a Dram of _Sal Ammoniack_ pulveriz'd; mingle these Ingredients together in a Brass-Bason, and let 'em be infus'd during a whole Night; then filtrate the Liquor and keep it for use. This _Collyrium_ is one of the best Medicines that can be prepar'd for all manner of Diseases of the Eyes. * * * * * CHAP. VII. _Of Powders._ * * * * * _A Powder against Madness or Frenzy._ Take the Leaves of Rue, Vervein, the lesser Sage, Plantain, Polypody, common Wormwood, Mint, Mother-Wort, Balm, Betony, St. _John_'s-Wort, and the lesser Centory; of every one an equal quantity. These Plants must be gather'd in the Month of _June_, during the clear and serene Weather, {340} and ty'd up in Nose-gays, or little Bundles; which are to be wrap'd up in Paper, and hung in the Air to be dry'd in the Shade. Afterward they are to be pounded in a great Brass-Mortar, and the Powder is to be sifted thro' a Silk-Sieve. The Dose of this Powder is from two to three Drams, mingl'd with half a Dram of the Powder of Vipers, in half a Glass of good White-Wine every Morning fasting, for fifty one Days successively. It has an admirable effect, provided the wounded Person be not bit in the Head nor Face, and that the Wound has not been wash'd with Water. * * * * * CHAP. VIII. _Styptick-Water._ Take _Colcothar_ or Red Vitriol that remains in the Retort after the Spirit has been drawn off, Burnt Allom, and Sugar-candy, of each thirty Grains; the Urine of a Young Person, and Rose-Water, of each half an Ounce; and two Ounces of Plantain-Water: Let the whole Mixture be stirr'd about for a long time, and then put into a Vial. But the Liquor must be pour'd off by Inclination when there shall be occasion to take any for use. {341} If a Bolster steept in this Water be laid upon an open Artery, and held close with the Hand, it will soon stop the Blood; a small Tent may be also soakt in it, and put up into the Nose for the same purpose. If it be taken inwardly, it stops the spitting of Blood, and the Dysentery or Bloody-Flux; as also the Hæmorrhoidal and Menstruous Fluxes; the Dose being from half a Dram to two Drams, in Knot-Grass-Water. * * * * * _FINIS._ * * * * * A TABLE OF THE CHAPTERS And of the Principal Matters Which are contain'd in every _Chapter_. * * * * * CHAP. I. _Of the Qualifications of a Surgeon, and the Art of Surgery,_ Page 1 _Of _Synthesis_, _Diæresis_, _Exæresis_, and _Prosthesis__ 2 _What ought to be observ'd before the undertaking of an Operation_ 3 CHAP. II. _Of Chirurgical Instruments, portable and not portable_ 5 CHAP. III. _Of Anatomy in general, and in particular of all the Parts of which the Human Body is compos'd_ 7 CHAP. IV. _Of the general Division of a Human Body_ 10 CHAP. V. _Of the Skeleton_ 12 _Of the different kinds of Articulations,_ 14 _Of the Number of the Bones of the Human Skeleton_ 16 CHAP. VI. _Of Myology, or the Description and Anatomy of the Muscles of the Human Body_ 19 CHAP. VII. _Of the Myology or Anatomy of the Muscles of the Head_ 21 CHAP. VIII. _Of the Myology or Anatomy of the Muscles of the Chest, or of the Breast, Belly, and Back_ 31 CHAP. IX. _Of the Myology or Anatomy of the Muscles of the lower Belly_ 34 _Of the Muscles of the Parts that serve for Generation in both Sexes_ 36 CHAP. X. _Of the Muscles of the Shoulder-Blades, Arms and Hands._ 37 CHAP. XI. _Of the Muscles of the Thighs, Legs, and Feet,_ 48 _A List of all the Muscles of the Humane Body,_ 57 CHAP. XII. _Of the Anatomy of the Nerves, Arteries, and Veins in general_ 58 _Of the Structure of the four Tunicks of the Arteries_ 61 _Of the Structure of the four Tunicks of the Veins_ 63 _Of the Beginning and Origine of all the Veins_ 64 _Of the Distribution of the ascending _Vena Cava__ Ibid. CHAP. XIII. _Of the Anatomy of the _Abdomen_ or lower Belly,_ 66 _Of the Opening of a dead Body at a publick Dissection_ 67 _Of the _Peristaltick_ Motion of the Guts_ 71 _Of the Parts appointed for Generation in Men_ 74 _Of the Parts appropriated to Generation in Women_ 75 CHAP. XIV. _Of the Anatomy of the Breast, or middle _Venter_,_ 77 _The manner of opening the Breast in order to dissect it_ Ibid. CHAP. XV. _Of the Anatomy of the Head or upper _Venter_,_ 80 _An exact Historical Account of the Holes of the Skull, and the Vessels that pass thro' 'em_ 83 _The manner of opening the Head, and Anatomizing the Brain_ 91 CHAP. XVI. _Of Straps, Swathing-Bands, Bandages, Bolsters, and Tents_ 93 A Treatise of Chirurgical Diseases. CHAP. I. _Of Tumours in general, Impostumes or Abcesses, Breakings out, Pustules, and Tubercles_ 97 CHAP. II. _Of the general Method to be observ'd in the curing of Tumours_ 100 _How many several ways may all curable Tumours be terminated_ 101 _What are the best means of curing Impostumes, whether to dissolve, or to bring 'em to Suppuration_ Ibid. _Of the Circumstances, to be observ'd by a Surgeon in the opening of Tumours_ 102 _Of the general Causes of Tumours_ 103 CHAP. III. _Of Natural Tumours, and first of the _Phlegmon_, and its Dependances_ 104 _Of Remedies proper for the _Phlegmon__ 105 _Remedies for the curing of _Aneurisms_ and _Varices__ 108 _Remedies for _Echymoses_, Contusions, or Bruises_ 109 _Of Tumours, and their Remedies_ 110 _Of a Gangrene_ 111 _Remedies for a Gangrene_ 113 _Of Kibes and Chilblains, and their Remedies_ 114 _Of the _Panaritium_ and its Remedies_ Ibid. _Of a Burn and its Remedies_ 115 _Of the _Erysipelas_ and its Dependences_ 116 _Remedies for the _Erysipelas__ Ibid. _Of _Erysipelatous_ Tumours or Impostumes, and their Remedies_ 118 _Of the _Oedema_, and its proper Remedies,_ 119 _Of _Oedomatous_ Tumours and Impostumes_ 120 _Of a _Scirrhus_ and its Remedies_ 123 _Of _Scirrhous_ Tumours_ 124 _Remedies for the _Polypus__ 125 _Of Cancers_ 126 _Remedies for Cancers_ Ibid. _and_ 127 CHAP. IV. _Of Bastard or _Encysted_ Tumours_ 128 _Of the Remedies for _Encysted_ Tumours_ 129 CHAP. V. _Of Critical, Malignant, Pestilential, and Venereal Tumours and Impostumes_ 131 CHAP. VI. _Of the Scurvy,_ 133 A Treatise of Wounds, Ulcers, and Sutures, CHAP. I. _Of Sutures or Stitches,_ 138 CHAP. II. _Of Wounds in general_ 141 _Of Remedies proper to stop the Hæmorrhage of a Wound_ 143 _What is to be done when a Convulsion happens in a Wound, by reason of a Wounded Nerve or Tendon_ 144 _What Course is to be taken to draw extraneous Bodies out of a Wound_ 145 _Of Vulnerary Decoctions to be taken inwardly_ 148 CHAP. III. _Of the particular Wounds of the Head_ 149 CHAP. IV. _Of the particular Wounds of the Breast_ 151 CHAP. V. _Of the particular Wounds of the lower Belly_ 153 CHAP. VI. _Of Wounds made by Guns or Fire-Arms_ 154 _Of the Prognostick of Wounds by Gun-shot_ 155 _Of the cure of Wounds by Gun-shot_ Ibid. _Of a Burn made by Gun-powder_ 159 CHAP. VII. _Of Ulcers in general_ 164 CHAP. VIII. _Of Venereal Diseases_ 168 _Of the _Chaude-Pisse_ or _Gonorrhæa__ Ibid. _Of Shankers_ 170 _Of Bubo's_ Ibid. _Of the Pox_ 171 _The manner of making the _Mercurial Panacæa__ 175, &c. A Treatise of the Diseases of the Bones. CHAP. I. _Of the Dislocation of Bones_ 181 CHAP. II. _Of the Fractures of Bones_ 187 CHAP. III. _Of the particular Fractures of the Skull_ 192 CHAP. IV. _Of the _Caries_, _Exostoses_, and _Nodus_ of the Bones_ 197 CHAP. V. _Of Cauteries, Vesicatories, Setons, Cupping-Glasses, and Leeches_ 199 _Of the compounding of Potential Cauteries_ 201 CHAP. VI. _Of Phlebotomy_ 204 A Treatise of Chirurgical Operations. CHAP. I. _Of the Operation of the _Trepan__ 209 _Of the Bandage of the _Trepan__ 213 CHAP. II. _Of the Operation of the _Fistula Lachrymalis__ 214 _The Dressing and Bandage of the _Fistula Lachrymalis__ 215 CHAP. III. _Of the Operation of the Cataract_ 216 _The Dressing and Bandage of the Operation of the Cataract_ 217 _Of purulent Matter gather'd under the Corneous Tunicle of the Eye_ 218 _Of a Tumour that ariseth in the Eye,_ Ibid. _Of the Eye-Lids glu'd together_ Ibid. _Of the Hairs of the Eye-Brows that offend the Eye_ 219 _Of the hard and transparent Tumours on the Eye-Lids_ Ibid. CHAP. IV. _Of the Operation of the _Polypus__ Ibid. CHAP. V. _Of the Operation of the Hare-Lip_ 220 _The Dressing and Bandage for the Hare-Lip_ 221 CHAP. VI. _Of the Operation of _Bronchotomy__ 222 CHAP. VII. _Of the Operation of the _Uvula__ 223 CHAP. VIII. _Of the Operation of a Cancer in the Breast_ Ibid. _The Dressing and Bandage of the Breast_ 225 CHAP. IX. _The Operation of the _Empyema__ 227 _The Dressing and Bandage for the Operation of the _Empyema__ 228 CHAP. X. _Of the Operation of the _Paracentesis_ of the lower Belly_ 229 _The Dressing and Bandage for that _Paracentesis__ 230 _The Operation of the _Parcentesis_ of the _Scrotum__ Ibid. CHAP. XI. _Of the Operation of _Gastroraphy__ 231 CHAP. XII. _Of the Operation of _Exomphalus__ 234 CHAP. XIII. _Of the Operation of the _Bubonocele_, and of the compleat Rupture_ 236 _The Dressing and Bandage_ 237 _Of the compleat Rupture_ Ibid. CHAP. XIV. _Of the Operation of _Castration__ 238 _Of the Dressing and Bandage for the _Castration__ 239 CHAP. XV. _Of the Operation of the Stone in the _Ureter__ 240 CHAP. XVI. _Of the Operation of _Lithotomy__ 241 _The Dressing and Bandage for the Operation of _Lithotomy__ 243 _Of the Operation of _Lithotomy_ in Women by the lesser Preparative_ 244 CHAP. XVII. _Of the Operation of the Puncture of the _Perinæum__ 245 CHAP. XVIII. _Of the Operation of the _Fistula in Ano__ Ibid. CHAP. XIX. _Of the Suture of Stitching of a Tendon_ 247 CHAP. XX. _Of the _Cæsarian_ Operation_ 248 CHAP. XXI. _Of the Operation of _Amputation_; with its proper Dressings and Bandages_ 249 and 251 CHAP. XXII. _Of the Operation of the _Aneurism__ 253 _The Bandage for the _Aneurism__ 255 CHAP. XXIII. _Of the Operation of _Phlebotomy__ Ibid. _The Bandage in _Phlebotomy__ 256 CHAP. XXIV. _Of the Operation of _Encysted_ Tumours_ 257 _Of _Ganglions__ 258 CHAP. XXV. _Of the Operation of _Hydrocephalus__ Ibid. CHAP. XXVI. _Of the Operation of cutting the Tongue-String_ 259 CHAP. XXVII. _Of the Operation of opening stopt _Ductus_'s_ 260 _Of an Incision made to open the _Vagina Uteri__ Ibid. _The manner of separating the Lips of the _Pudendum_ when conglutinated_ Ibid. _The manner of opening the _Vagina_ when stopt with a Fleshy Substance_ Ibid. _The Method of opening the Urinary _Ductus_ as well in Boys as in young Virgins_ Ibid. _The Method of opening the _Ductus_ of the Ear, when stopt with a Membrane or a Carnous Substance_ 261 CHAP. XXVIII. _Of the Operation of the _Phimosis_ and _Paraphimosis__ Ibid. CHAP. XXIX. _Of the Operation of the _Varix__ 262 CHAP. XXX. _Of the Operation of the _Panaritium__ 263 _The Dressing and Bandage for this Operation_ Ibid. CHAP. XXXI. _Of the Reduction of the falling of the _Anus__ 264 CHAP. XXXII. _Of the reducing of the falling of the _Matrix__ 265 CHAP. XXXIII. _Of the application of the Cautery and its Bandage_ Ibid. CHAP. XXXIV. _Of the Application of Leeches, and the Dressing_ 267 CHAP. XXXV. _Of the application of the _Seton__ 268 CHAP. XXXVI. _Of Scarifications_ 269 CHAP. XXXVII. _Of the Application of _Vesicatories__ Ibid. CHAP. XXXVIII. _Of the application of Cupping-Glasses_ 270 CHAP. XXXIX. _Of the opening of Abscesses or Impostumes_ 271 A Treatise of the Operations of Fractures. CHAP. I. _Of the Fracture of the Nose_ 272 _The Dressing and Bandage for the Fracture of the Nose_ 273 CHAP. II. _Of the Fracture of the lower Jaw_ 274 _The Dressing and Bandage_ Ibid. CHAP. III. _Of the Fracture of the _Clavicle__ 276 _The Dressing and Bandage_ Ibid. CHAP. IV. _Of the Fracture of the _Omoplata_ or Shoulder-Blade_ 278 _The Dressing_ Ibid. CHAP. V. _Of the Fracture of the Ribs_ 279 _The Dressing and Bandage_ 280 CHAP. VI. _Of the Fracture of the _Sternum_ or Breast-Bone_ Ibid. _The Dressing and Bandage_ 281 CHAP. VII. _Of the Fracture of the _Vertebra's__ Ibid. CHAP. VIII. _Of the Fracture of the _Os Sacrum__ 283 CHAP. IX. _Of the Fracture of the _Coccyx_ or Rump-Bone_ Ibid. _The Dressing and Bandage for that Fracture_ 284 CHAP. X. _Of the Fracture of the _Humerus_ or Arm-Bone_ Ibid. _Its proper Dressing and Bandage_ 285 CHAP. XI. _Of the Fracture of the Bone of the Elbow_ 286 _The Dressing and Bandage_ Ibid. CHAP. XII. _Of the Fracture of the _Carpus_ or Wrist-Bone_ 287 _The Dressing and Bandage_ Ibid. CHAP. XIII. _Of the Fracture of the Bone of the _Metacarpium_ or Back of the Hand_ 288 _The Dressing and Bandage_ Ibid. CHAP. XIV. _Of the Fracture of the Bones of the Fingers_ 289 CHAP. XV. _Of the Fracture of the Thigh-Bone_ Ibid. _The Dressing and Bandage_ 290 CHAP. XVI. _Of the Fracture of the _Patella_ or Knee-Pan_ 291 _The Dressing and Bandage_ Ibid. CHAP. XVII. _Of the Fracture of the Leg-Bone_ 292 _Its proper Dressing and Bandage_ 293 _The Dressing for complicated Fractures_ 294 CHAP. XVIII. _Of the Fracture of the Bones of the Foot_ 295 _The Dressing and Bandage_ 296 A Treatise of the Operations which are perform'd in Luxations. CHAP. I. _Of the Luxation of the Bone of the Nose_ 297 _The Dressing and Bandage proper for such a Luxation_ 298 CHAP. II. _Of the Luxation of the lower Jaw-Bone_ Ibid. _The Dressing and Bandage_ 299 CHAP. III. _Of the Luxation of the _Clavicle__ Ibid. CHAP. IV. _Of the Luxation of the _Vertebra_'s_ 300 _The Dressing and Bandage_ 301 CHAP. V. _Of the Luxation of the _Coccyx_ or Rump-Bone_ 302 CHAP. VI. _Of the Bunch_ Ibid. CHAP. VII. _Of the Luxation of the Ribs_ 303 _The Dressing and Bandage_ Ibid. CHAP. VIII. _Of the sinking of the _Xiphoides_ or Sword-like Cartilage_ 304 CHAP. IX. _Of the Luxation of the _Humerus_ or Arm-Bone,_ Ibid. _The Dressing and Bandage_ 306 CHAP. X. _Of the Luxation of the Bone of the Elbow_ Ibid. _The Bandage for the same Luxation_ 307 CHAP. XI. _Of the Luxation of the _Carpus_ or Wrist-Bone_ 308 _The Bandage_ 309 CHAP. XII. _Of the Luxation of the Bones of the Fingers_ Ibid. _The Bandage for that Luxation_ Ibid. CHAP. XIII. _Of the Luxation of the Thigh_ 310 _Its proper Dressing and Bandage_ 312 CHAP. XIV. _Of the Luxation of the Knee_ Ibid. _The Bandage_ 313 CHAP. XV. _Of the Luxation of the _Patella_, Knee-Pan, or Whirl-Bone of the Knee_ Ibid. _Of the Separation of the _Perone_ from the_ Tibia Ibid. _Of the Luxation of the _Astragalus__ 314 _Of the Separation of the _Calcaneum_ from the _Astragalus__ Ibid. A Treatise of Medicinal Compositions necessary for a Surgeon. CHAP. I. _Of Balsams_ 315 _The Balsam of _Arcæus__ Ibid. _The Balsam of _Spain__ 316 _The Green Balsam_ 317 _The _Samaritan_ Balsam_ 318 CHAP. II. _Of Ointments_ 319 __Unguentum Althææ__ Ibid. _The mundificative Ointment of Smallage_ 320 _The black or suppurative Ointment_ 321 __Unguentum Rosatum__ 322 __Unguentum Album, aut de Cerussa__ 323 __Unguentum Ægyptiacum__ 324 __Unguentum Basilicon_, or the Royal Ointment_ 325 _A cooling Cerate_ 326 _An Ointment for Burns_ 327 CHAP. III. _Of Plaisters_ 328 _Of Plaister of _Diapalma__ Ibid. _The Plaister of simple _Diachylum__ 329 _The Plaister of _Andreas Crucius__ 330 __Emplastrum Divinum__ 331 CHAP. IV. _Of the Cataplasms or Pultisses_ 332 CHAP. V. _Of Oils_ 334 _Simple Oil of Roses made by infusion_ Ibid. _Compound Oil of Roses made by infusion_ Ibid. _Oil of sweet Almonds made by expression_ 335 _Oil of Bayes_ 336 _Oil of Eggs made by expression_ 337 CHAP. VI. _Of _Collyriums__ 338 _A dry _Collyrium__ Ibid. _A blue _Collyrium__ 339 CHAP. VII. _Of Powders_ Ibid. _A Powder against Madness or Frenzy_ Ibid. CHAP. VIII. _A Styptick Water_ 340 The END of the TABLE. * * * * * Transcriber's note: Changes made to the printed copy. Page 20. "causeth the Antagonist to swell": 'Anatgonist' in original. Page 29. "which arising from the fore-part on the inside": 'ari-rising' on line break in original. Page 30. "The Scalenus or Triangularis": 'Scalenu' in original. Page 36. "round ligament of the Matrix": 'liga-' appears only as the catch-word in original. Page 113. "the mortify'd and corrupt Parts": 'morrify'd' in original. Page 117. "and often renew'd": 'ond often renew'd' in original. Page 118. "Tumours or Impostumes that partake": 'parrake' in original. Page 130. "reiterated Purgations": 'reirerated' in original. Page 146. "Oyl of Hemp-seed": 'Hmp-seed' in original. Page 160. "which may be laid altogether": 'be be' in original. Page 180. "all sorts of Venereal Diseases": 'Venenereal' in original. Page 202. "In what Parts is the Seton to be apply'd?": 'to Seton be' in original. Page 216. "taking a Steel-Needle": 'a a' on line break in original. Page 229. "This Dressing is to be kept close": 'kepc' in original. Page 237. "to make a good Cicatrice or Scar.": 'to to' on line break in original. Page 249-50. "the Periosteum is to be scrap'd": 'be' catch-word only, not in text in original. Page 252. "round about the Stump": 'the about the' in original. Page 269. "with a warm cloth": 'wram' in original. Page 288. "the Shape of the Part": 'Skape' in original. Page 299. "but remains somewhat open": 're-remains' on line break in original. Page 302. "requisite to keep Emollients": 'lo keep' in original. TOC. "Of the Muscles of the Parts that serve for Generation": 'Geration' in original. 
21280	----	[Illustration: FRONTISPIECE. Photo, H. KISCH Ladysmith. Engraved and Printed by Bale and Danielsson, Ltd.] SURGICAL EXPERIENCES IN SOUTH AFRICA 1899-1900 BEING MAINLY A CLINICAL STUDY OF THE NATURE AND EFFECTS OF INJURIES PRODUCED BY BULLETS OF SMALL CALIBRE BY GEORGE HENRY MAKINS, F.R.C.S. SURGEON TO ST. THOMAS'S HOSPITAL, LONDON JOINT LECTURER ON SURGERY IN THE MEDICAL SCHOOL OF ST. THOMAS'S HOSPITAL MEMBER OF THE COURT OF EXAMINERS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND, AND LATE ONE OF THE CONSULTING SURGEONS TO THE SOUTH AFRICAN FIELD FORCE LONDON SMITH, ELDER, & CO., 15 WATERLOO PLACE 1901 TO SURGEON-GENERAL W. D. WILSON PRINCIPAL MEDICAL OFFICER TO THE SOUTH AFRICAN FIELD FORCE THE MEMBERS OF THE ROYAL ARMY MEDICAL CORPS EMPLOYED IN SOUTH AFRICA AND TO THE CIVIL SURGEONS TEMPORARILY ATTACHED TO THAT CORPS These Experiences are Dedicated AS AN EXPRESSION OF APPRECIATION OF THE INVARIABLE KINDNESS AND SYMPATHY EXTENDED TO THE AUTHOR WITHOUT WHICH THE BOOK COULD NOT HAVE BEEN WRITTEN PREFACE A word of explanation is perhaps necessary as to the form in which these experiences have been put together. The matter was originally collected with the object of sending a series of articles to the _British Medical Journal_. Various circumstances, however, of which the chief was the feeling that extending experience altered in many cases the views adopted at first sight, prevented the original intention from being carried into execution, and the articles, considerably expanded, are now published together. As to the illustrative cases introduced in support of various statements made in the text, only those have been chosen from my notes which were under my own observation for a considerable time, and many of these have been brought up to date since my return to England. I have, as a rule, avoided the inclusion of cases seen cursorily, and few simple ones have been quoted since their character is sufficiently indicated in the text. These remarks seem necessary since the mode of selection has resulted in the inclusion of a number of cases of exceptional severity, and any attempt to draw statistical conclusions from them would be most misleading. The first two chapters have been added with a view to affording some information, first, as to the conditions under which a great part of the surgical work was done, and, secondly, as to the mechanism and causation of the injuries, which would not readily be at hand in the case of the general surgical reader. For much of the information contained in Chapter II. I must express my indebtedness to the work of MM. Nimier and Laval, so frequently quoted. The only other object of this Preface is to express my thanks to the many who have aided me in the task of amplifying the observations on which the articles are founded, and I think no writer ever received more sympathetic and kindly help in such particulars than the author. My first thanks, those due to the Members of the Royal Army Medical Corps, I endeavour to express by the dedication of this volume. Any attempt to make individual acknowledgment to either the Members of the Service, or to the Civil Surgeons temporarily attached, would be impossible. I have, however, tried to associate the names of many of those in charge of cases in the recital of histories and treatment throughout. My thanks are not less due to the Military Heads of Departments at the War Office, who have helped me in the collection of details as to the subsequent course of many of the cases described, and in the acquisition of information regarding the weapons and ammunition treated of. I should particularly express my gratitude to Colonel Robb, of the Adjutant-General's Department, and Colonel Montgomery, of the Ordnance Department. I am greatly indebted to my former colleague Mr. Cheatle for two of the illustrations of wounds, and for permission to quote some of his other experience, and to Mr. Henry Catling, to whose skill I owe the majority of the skiagrams of the fractures under my observation at Wynberg and elsewhere. I must also express my thanks to Mr. Danielsson and his artist, Mr. Ford, for the trouble they have taken in converting my rough sketches into the illustrations contained in the volume. Lastly, my warmest gratitude is due to my friends, Mr. Cuthbert Wallace, who has read some of my chapters, and to Mr. F. C. Abbott, who has read the whole book for the press and suggested many improvements and modifications. 47 CHARLES STREET, BERKELEY SQUARE, W. _February_ 1901. CONTENTS PAGE CHAPTER I INTRODUCTORY Itinerary--Surgical outfit--Personal transport--General health of the troops--Climate--Consideration of the number of men killed and wounded--Transport of the wounded--Vehicles--Trains--Ships--Hospitals 1 CHAPTER II MODERN MILITARY RIFLES AND THEIR ACTION General type--Calibre, length, and weight of bullet--Velocity--Trajectory--Revolution--Varieties of rifle in common use by the Boers--Penetration--Comparison of bullets--Use of wax--Comparative efficiency of different types 40 CHAPTER III GENERAL CHARACTERS OF WOUNDS INFLICTED BY BULLETS OF SMALL CALIBRE Type wounds--Nature of external apertures--Direct course of wound track--Multiple wounds--Small bore and sharp localisation of tracks--Clinical course--Mode of healing--Suppuration--Wounds of irregular type--Ricochet--Mauser bullet--Lee-Metford bullet--Expanding bullets--Altered bullets--Large sporting bullets--Symptoms--Psychical disturbance and shock--Local shock--Pain--Hæmorrhage--Diagnosis--Prognosis--Treatment 55 CHAPTER IV INJURIES TO THE BLOOD VESSELS Nature of lesions; contusion, laceration, perforation--Results of injuries--Primary hæmorrhage--Recurrent hæmorrhage--Secondary hæmorrhage--Treatment of hæmorrhage--Traumatic aneurisms--Arterial hæmatoma--True traumatic aneurism--Aneurismal varix and varicose aneurism--Conditions affecting development--Effects of aneurismal varix or varicose aneurism on the general circulation--Prognosis and treatment of aneurismal varix--Prognosis and treatment of varicose aneurism--Gangrene after ligation of arteries 112 CHAPTER V INJURIES TO THE BONES OF THE LIMBS Nature of wounds--Explosive wounds--Types of fracture of shafts of long bones--Stellate, wedge, notch, oblique, transverse, perforating--Fractures by old types of bullet--Lesions of the short and flat bones--Special character of the symptoms in gunshot fracture, and of the course of healing--Prognosis--Treatment--Special fractures--Upper extremity--Pelvis--Lower extremity 154 CHAPTER VI INJURIES TO THE JOINTS General character--Vibration synovitis--Wounds of joints--Classification--Course and symptoms--General treatment--Special joints 225 CHAPTER VII INJURIES TO THE HEAD AND NECK Anatomical lesions--Scalp wounds--Fracture of the skull without evidence of gross lesion of the brain--Fractures with concurrent brain injury--Classification--General injuries--Effect of ricochet--Vertical or coronal wounds in frontal region--Glancing or oblique wounds of any region--Gutter fractures--Superficial perforating fractures--Fractures of the base--Symptoms of fracture of the skull, with concurrent injury to the brain--Concussion--Compression--Irritation--Frontal injuries--Fronto-parietal and parietal injuries--Occipital injuries--Forms of hemianopsia--Abscess of the brain--General diagnosis--General prognosis--Traumatic epilepsy--General treatment--Wounds of the head not involving the brain--Mastoid process--Orbit--Globe of the eye--Nose--Malar bone--Upper jaw--Mandible--Wounds of the neck--Wounds of the pharynx, larynx, and trachea 241 CHAPTER VIII INJURIES TO THE VERTEBRAL COLUMN AND SPINAL CORD Fractures in their relation to nerve injury--Transverse processes--Spinous processes--Centra--Signs of fracture of the vertebra--Injuries to the spinal cord--Effects of high velocity--Concussion, slight, severe--Contusion--Hæmorrhage, extra-medullary, hæmatomyelia--Symptoms of injury to the spinal cord--Concussion--Hæmorrhage--Total transverse lesion--Diagnosis of form of lesion--Prognosis--Treatment 314 CHAPTER IX INJURIES TO THE PERIPHERAL NERVES Anatomical lesions--Concussion--Contusion--Division or laceration--Secondary implication of the nerve--Symptoms of nerve injury--Traumatic neuritis--Scar implication--Ascending neuritis--Traumatic neurosis--Injuries to special nerves--Cranial nerves--Cervical, brachial, lumbar, and sacral plexuses--Cases of nerve injury--General prognosis and treatment 341 CHAPTER X INJURIES TO THE CHEST Non-penetrating wounds of the chest wall--Penetrating wounds, special characters of entrance and exit apertures--Fracture of the ribs, symptoms, treatment--Wounds of the diaphragm--Wounds of the heart--Wounds of the lung, symptoms--Pneumothorax--Hæmothorax-- Empyema--Diagnosis, prognosis, and treatment of hæmothorax--Cases of hæmothorax 374 CHAPTER XI INJURIES TO THE ABDOMEN Introductory remarks--Wounds of the abdominal wall--Penetration of the intestinal area without definite evidence of visceral injury--Wounds of explosive character--Anatomical characters of intestinal wounds--Wounds of the mesentery---Wounds of the omentum--Results of intestinal wounds, fæcal extravasation, peritoneal infection, septicæmia--Reasons for the escape of severe injury in wounds traversing the abdomen--Wounds of the stomach--Wounds of the small intestine--Wounds of the large intestine--Prognosis in intestinal injuries--Treatment of intestinal injuries--Wounds of the urinary bladder--Wounds of the kidney--Wounds of the liver--Wounds of the spleen--General remarks on the prognosis in abdominal injuries--Wounds of the external genital organs--Wounds of the urethra 407 CHAPTER XII ON SHELL WOUNDS Varieties of shells employed--Large shells--Wounds produced by different varieties--Pom-Pom shells--Wounds produced by fragments and fuses--Shrapnel--Boer segment shells--Leaden shrapnel bullets--Treatment of shell wounds 474 INDEX OF CONTENTS 487 ILLUSTRATIONS _PLATES_ VARIETIES OF AMMUNITION COLLECTED AT LADYSMITH _Frontispiece_ 1. SECTION OF MAUSER APERTURE OF ENTRY _To face p._ 73 2. SECTION OF MAUSER APERTURE OF EXIT 76 3. PUNCTURED FRACTURE OF CLAVICLE 162 4. COMMINUTED FRACTURE OF SHAFT OF HUMERUS 180 5. COMMINUTED FRACTURE OF HUMERUS ACCOMPANIED BY AN EXPLOSIVE EXIT 182 6. COMMINUTED FRACTURE OF HUMERUS DUE TO OBLIQUE IMPACT 184 7. SAME FRACTURE HEALED 186 8. LOW VELOCITY FRACTURE OF HUMERUS WITH RETAINED BULLET 188 9. LOCALISED FRACTURE OF HUMERUS SHOWING FRAGMENTATION OF THE BULLET 190 10. WEDGE-SHAPED FRACTURE OF THE RADIUS 192 11. FRACTURE OF THE METACARPUS, SHOWING FRAGMENTATION OF THE BULLET 194 12. FINELY COMMINUTED FRACTURE OF THE FEMUR 196 13. THE SAME FRACTURE HEALED 198 14. STELLATE 'BUTTERFLY' FRACTURE OF THE FEMUR 200 15. LATERAL IMPACT OF BULLET, WITH COMMINUTION OF THE FEMUR 202 16. RECTANGULAR IMPACT OF BULLET, WITH HIGHLY OBLIQUE LINE OF FRACTURE OF THE FEMUR 204 17. PUNCTURED FRACTURE OF THE FEMUR WITH EXIT BONE-FLAP 206 18. FRACTURED PATELLA 208 19. OBLIQUE COMMINUTED FRACTURE OF THE TIBIA 210 20. TRANSVERSE FRACTURE OF THE TIBIA 212 21. PUNCTURE OF THE TIBIA, WITH AN OBLIQUE FISSURE 214 22. NOTCHED FRACTURE OF THE TIBIA 216 23. PUNCTURED FRACTURE OF THE FIBULA 218 24. THE SAME FRACTURE, LATERAL VIEW 220 25. VICKERS-MAXIM FRACTURE OF THE HUMERUS 482 _IN THE TEXT_ FIG. PAGE 1. LINEN HOLD-ALL WITH INSTRUMENTS 4 2. INSTRUMENT HOLD-ALL ROLLED FOR PACKING 5 3. TIN WATER-BOTTLE FOR EMERGENCY OPERATIONS 6 4. BUGGY ON THE VELDT 7 5. MCCORMACK-BROOK WHEELED STRETCHER CARRIAGE 19 6. INDIAN TONGA 20 7. SERVICE AMBULANCE WAGON 21 8. BUCK-WAGON LOADED WITH WOUNDED MEN 22 9. INTERIOR OF A WAGON OF NO. 2 HOSPITAL TRAIN 24 10. P. & O. HOSPITAL SHIP 'SIMLA' 25 11. TYPE OF GENERAL HOSPITAL 32 12. TYPE OF TORTOISE TENT HOSPITAL 33 13. SINGLE TORTOISE HOSPITAL TENT 35 14. FIVE TYPES OF CARTRIDGE IN COMMON USE DURING THE WAR 47 15. SECTIONS OF FOUR BULLETS TO SHOW RELATIVE THICKNESS OF MANTLES 51 16. ENTRY AND EXIT MAUSER WOUNDS 56 17. GUTTER WOUND OF SHOULDER 56 18. OBLIQUE GUTTER EXIT WOUND 57 19. OVAL ENTRY, STARRED EXIT WOUNDS 58 20. CIRCULAR ENTRY, SLIT EXIT WOUNDS 59 21. CIRCULAR ENTRY, STARRED EXIT WOUNDS 59 22. ENTRY AND EXIT WOUNDS IN SIX SUCCESSIVE SPOTS MADE BY SAME BULLET 61 23. FOUR SUCCESSIVE ENTRY AND EXIT WOUNDS OF SAME BULLET 62 24. SUPERFICIAL ABDOMINO-THORACIC TRACK 64 25. SUPERFICIAL LINEAR ECCHYMOSIS OF THIGH 65 25_a_. SECTIONS OF MAUSER ENTRY AND EXIT WOUNDS 74 25_b_. PROLAPSED OMENTUM 77 26. SECTIONS OF FOUR BULLETS 82 27. NORMAL MAUSER BULLET 83 28. FOUR MAUSER RICOCHETS 84 29. MAUSER RICOCHET, DISC FORM 85 30. FISSURED MAUSER MANTLE 86 31. MAUSERS DEFORMED BY IMPACT ON FEMUR 86 32. APICAL MAUSER RICOCHET 87 33. SPIRAL RICOCHET 88 34. NORMAL LEE-METFORD BULLET 89 35. APICAL LEE-METFORD RICOCHETS 90 36. " " " 91 37. FOUR TYPES OF SOFT-NOSED BULLETS 92 38. 'SET-UP' SOFT-NOSED LEE-METFORD BULLETS 92 39. FLATTENED, SOLID-BASED MANTLE FROM RICOCHET 93 40. MAUSER BULLET, JEFFREYS-TWEEDIE MODIFICATION 94 41. SECTION OF MARK IV. AND SOFT-NOSED MAUSER 94 42. TAMPERED BULLETS 95 43. LARGE LEADEN SPORTING BULLETS 98 44. EXPLOSIVE WOUND OF BACK 100 45. DEAD MEN ON FIELD OF BATTLE 102 46. FLATTENED LEADEN CORES FROM MANTLED BULLETS 105 47. EXPLOSIVE EXIT WOUND OVER FRACTURED ULNA 156 48. EXPLOSIVE EXIT WOUND OVER FRACTURED HUMERUS 158 49. EXPLOSIVE EXIT AND ENTRY WOUNDS OF LEGS 159 50. TYPES OF GUNSHOT FRACTURE 161 51. LOWER END OF FRACTURED FEMUR 164 52. OBLIQUE PERFORATION OF FEMUR, SEPARATION OF FRAGMENT AT EXIT APERTURE IN BONE 169 53. GUTTER FRACTURE OF HEAD OF HUMERUS 178 53_a._ DIAGRAM OF 'BUTTERFLY' TYPE 180 54. WIRE GAUZE SPLINT 187 55. GUTTER FRACTURE OF PELVIS 191 55_a_. DIAGRAM OF 'BUTTERFLY' TYPE 200 56. CANE FIELD SPLINT FOR LOWER EXTREMITY 209 57. TUNNEL FRACTURE AT SURFACE OF TIBIA 219 58. CANE FIELD SPLINT FOR LEG 222 59. SKIAGRAM OF INJURY TO INTERPHALANGEAL JOINT 237 60. SKIAGRAM OF BULLET IN NASAL FOSSA 244 61. DIAGRAM OF APERTURE OF ENTRY INTO CRANIUM 245 62. APERTURE OF ENTRY INTO FRONTAL BONE 252 63. FRAGMENT OF INNER TABLE DISPLACED FROM OPENING SEEN IN FIG. 62 253 64. GUTTER FRACTURE OF FIRST DEGREE IN PARIETAL BONE 255 65. DIAGRAM OF GUTTER FRACTURES 256 66. GUTTER FRACTURE OF SECOND DEGREE IN PARIETAL BONE 257 67. DIAGRAMS OF GUTTER FRACTURES 258 68. SUPERFICIAL PERFORATING FRACTURE OF PARIETAL REGION 259 69. DIAGRAM OF SUPERFICIAL PERFORATING FRACTURE 260 70. FRAGMENT FORMING FLOOR OF TEMPORAL GUTTER FRACTURE 260 71. SCALE OF EXTERNAL TABLE IN LOW VELOCITY INJURY OF FRONTAL BONE 261 72. FRONTAL PERFORATION, APERTURE OF EXIT 261 73. VISUAL FIELD IN OCCIPITAL INJURY 279 74. " " " 279 75. " " " 281 76. " " " 281 77. " " " 283 78. " " " 283 79. CONTUSED SPINAL CORD 333 80. DIVIDED SPINAL CORD 334 81. SUPERFICIAL TRACK IN ANTERIOR BODY-WALL 377 82. SPIRALLY GROOVED BULLET 381 83. ECCHYMOSIS IN FRACTURED RIBS WITH HÆMOTHORAX 392 84. SUBCUTANEOUS DIVISION OF ABDOMINAL MUSCLES 409 85. LATERAL INCOMPLETE WOUND OF SMALL INTESTINE. SLIT FORM 416 86. LATERAL PERFORATION OF SMALL INTESTINE. GUTTER FORM 417 87. ENTRY AND EXIT WOUNDS IN A TRANSVERSE PERFORATION OF INTESTINE 418 88. INNER ASPECT OF PIECE OF INTESTINE SHOWN IN FIG. 87 419 89. IMPACTION OF OMENTUM IN EXIT WOUND OF ABDOMINAL WALL 421 90. FRAGMENTS OF LARGE SHELLS 475 91. FRAGMENTS OF PERCUSSION AND TIME FUSES 477 92. COMPLETE 1-LB. POM-POM SHELL 479 93. FRAGMENTS OF EXPLODED POM-POM SHELLS 480 94. PERCUSSION FUSE FROM 1-LB. POM-POM SHELL 481 95. FRAGMENTS OF BOER SEGMENT SHELLS 483 96. NORMAL AND DEFORMED LEADEN SHRAPNEL BULLETS 485 _TEMPERATURE CHARTS_ 1. CASE OF AXILLARY HÆMATOMA, BLOOD TEMPERATURE 119 2. CASE OF HÆMOTHORAX WITH RECURRENT HÆMORRHAGES 395 3. PRIMARY AND SECONDARY RISES OF TEMPERATURE IN HÆMOTHORAX, RECOVERING SPONTANEOUSLY 402 4. SECONDARY RISE OF TEMPERATURE IN HÆMOTHORAX 403 5. FALLS OF TEMPERATURE IN HÆMOTHORAX FOLLOWING PARACENTESIS 404 6. SECONDARY HÆMOTHORAX, SPONTANEOUS FALL OF TEMPERATURE 405 SURGICAL EXPERIENCES IN SOUTH AFRICA CHAPTER I INTRODUCTORY The following pages are intended to give an account of personal experience of the gunshot wounds observed during the South African campaign in 1899 and 1900. For this reason few cases are quoted beyond those coming under my own immediate observation, and in the few instances where others are made use of the source of quotation is indicated. It will be noted that my experience was almost entirely confined to bullet wounds, and in this respect it no doubt differs from that of surgeons employed in Natal, where shell injuries were more numerous. This is, however, of the less moment for my purpose as there is probably little to add regarding shell injuries to what is already known, while, on the other hand, the opportunity of observing large numbers of injuries from rifle bullets of small calibre has not previously been afforded to British surgeons. I think the general trend of the observations goes to show that the employment of bullets of small calibre is all to the advantage of the men wounded, except in so far as the increased possibilities of the range of fire may augment the number of individuals hit; also that such variations as exist between wounds inflicted by bullets of the Martini-Henry and Mauser types respectively, depend rather on the form and bulk of the projectile than on any inherent difference in the nature of the injuries. Thus in the chapter devoted to the general characters of the wounds, it will be seen that most of the older types of entry and exit aperture are produced in miniature by the small modern bullet, and that the main peculiarity of the deeper injuries is the frequent strict localisation of the direct damage to an area of no greater width than that crossed by narrow structures of importance such as arteries or nerves. It is to be regretted that I am unable to furnish any important statistical details, but incomplete numbers, such as are at my disposal, would be of little value. In view, however, of the considerable interval which must elapse before the Royal Army Medical Corps is able to arrange and publish the large material which will have accumulated, it has seemed unwise to defer publication until the completion of a report which will deal with such matters thoroughly. It may be of interest to premise the opportunities which I enjoyed of gaining experience during the campaign. I arrived in South Africa on November 19, 1899; two days later I proceeded to Orange River with Surgeon-General Wilson, and on the day three weeks after leaving home performed some operations in the field hospitals on patients from the battle of Belmont. I remained at Orange River during the three next engagements, Graspan, Enslin, and Modder River, and on the day of Magersfontein I went forward to the Field hospitals at Modder River, arriving during the bringing in of the patients from the field of battle. I returned to Orange River with the patients and remained there a further period of three weeks, during which time the patients were gradually transferred to the Base hospitals at Wynberg. At Christmas I followed the patients down to the base, and thus was able to observe the course of the cases from their commencement to convalescence. I remained at Wynberg six weeks, during which time a number of cases from the neighbourhood of Rensburg and some from Natal were received. On February 7, I left Wynberg, following Lord Roberts up to my old quarters at Modder River, where I saw a few wounded men brought in from the engagements at Koodoosberg Drift. On Lord Roberts's departure for Bloemfontein he requested me to return to Wynberg to await the wounded who might be sent down from the fighting which might occur during his advance. I therefore had the disappointment of seeing the start of the army, and then returning to Wynberg, where I remained for another six weeks in attendance at Nos. 1 and 2 General Hospitals. During this period a very large number of the wounded from Paardeberg Drift and other battles were sent down and treated, after which surgical work began to flag. On April 14, I was recalled to the front and journeyed to Bloemfontein, where I stayed three weeks, making one journey out to the Bearer Company of the IX. Division at the Waterworks. On May 4, I left Bloemfontein with Lord Roberts's army, and shortly after joined the IX. Division, with which I journeyed until the commencement of June, seeing a good deal of scattered work in the field and Field hospitals, and in the small temporary improvised hospitals in the towns of Winberg, Lindley, and Heilbron. Early in June I left Heilbron with Lord Methuen's division, and spent the next four weeks with this division in the field. Thence I journeyed to Pretoria and Johannesburg, seeing a small number of wounded in each town, and on July 10, with Lord Roberts's consent, I started for home, visiting a number of the hospitals in the Orange River Colony and Natal on my way down to Cape Town. During the movements briefly recorded above, which absorbed a period of nine months, my time was fairly evenly divided between Field, Stationary, and Base hospitals; hence I had opportunities of observing the patients in every stage of their illnesses, and in all some thousands of men came under my notice. [Illustration: FIG. 1.--Linen Holdall with surgical instruments] My departure for the seat of war was rather hurried, hence my surgical equipment was not of an extensive nature. It may be of interest, however, to shortly recount what it consisted in, since it proved an ample one, and yet was carried in a small satchel. The plan of selection adopted consisted in carefully going through the equipment of the British Field Hospital, and then adding such other instruments as seemed to me likely to be useful. With few exceptions, therefore, designed to meet emergencies, my set of instruments formed a supplement to the actual necessities carried by the Service hospitals, and was as follows:--4 trephines, Horsley's elevator, brain knife and seeker. 2 pairs of Hoffman's and 1 pair of Lane's fulcrum gouge forceps, 3 bone gouges, 1 pair straight 1 curved necrosis forceps, 1 pair bone forceps. 1 Wood's 1 Horsley's skull saws, 18 Gigli's saws with an extra handle, and two Podrez' directors for the same. 1 set Lane's bone drills, broaches, screw-drivers, and counter-sink with eight ounces of screws: silver patella wire, and 1 pair Peter's bone forceps. 2 aneurism needles, 1 bullet probe, 1 pair Egyptian Army pattern bullet forceps. 4 Lane's and 3 pairs Makins's bowel clamps, Nos. 3 4 and 5 Laplace's bowel forceps, 6 Murphy's buttons, 1 pair Morris's retractors, 6 dozen intestine needles, 2 Macphail's needle-holders, Nos. 4 5 6 Thomas's slot-eyed needles, 1 mouth gag, 1 Durham's double raspatory, 3 strong plated raspatories, 1 pair tongue forceps, 1 tracheal dilator, 1 pair hernia needles, 1 hernia and 1 ordinary steel director, 1 transfusion set with metal funnel, and a stock of Messrs. Burroughes and Wellcome's compound saline infusion soloids. 1 antitoxin syringe. 6 scalpels, 2 blunt-pointed curved bistouries, 6 forcipressure forceps, 1 pair Jordan Lloyd's retractors, 1 pair ordinary retractors, 2 pairs of forceps, 3 pairs of Scissors, 1 skin-grafting razor and roll of perforated tin foil, 1 metal pocket case, and 1 hypodermic syringe with tabloids. A stock of silkworm gut, horsehair and silk ligatures, the latter prepared and sterilised for me by Miss Taylor, the Theatre Sister at St. Thomas's Hospital. Some pairs of McBurney's india-rubber, and cotton-thread operating gloves. [Illustration: FIG. 2.--Instrument Holdall rolled] The instruments were packed in sets in small linen holdalls suggested and made by Messrs. Down Bros., who also devised my satchel. In the light of the experience gained I should have preferred a tin case to the satchel, as it never needed to be carried on horseback. For dressings I trusted entirely to the Royal Army Medical Corps, and at my request Colonel Gubbins, R.A.M.C., sent out to the Cape a quantity of sterilised sponges and pads made by Messrs. Robinson & Co. Ltd. of Chesterfield, which fully met all requirements in this direction. [Illustration: FIG. 3.--Tin Water-bottle for the march (Military Equipment Company)] This equipment was superfluous at the Base hospitals, but when in the field with the troops proved very useful. In the early part of the campaign I was able to do all my travelling by train, but later I travelled by road only. I received the greatest kindness and help in this particular. General Sir William Nicholson, Chief Director of Transport, provided me with a buggy, a pair of horses, and a driver, and Prince Francis of Teck, the Chief Remount Officer, selected a pony suitable to my equestrian powers. The buggy proved a very great success; the box seat carried my instruments and dressings, the front a 4-gallon tin water-bottle for emergency operations, and the rear shelf my personal belongings. The water-bottle was lent to me by the Portland Hospital. (Fig. 3.) The cart was able to cross any drifts or dongas, and when an engagement was in progress was able to accompany the Ambulance wagons, so that I had all my necessaries on the spot, even at the first dressing station. In point of fact when with the Highland Brigade, on some occasions, we did all necessary operations on the spot during the progress of fighting; a most useful performance, since fighting on several days did not cease till dark, and the evenings were much too cold to allow of operations being done with safety to the patients. The great advantage of the buggy was its lightness and smallness. On one occasion it accompanied me between 500 and 600 miles without a single accident, beyond the fact that one night I was relieved of both my horses by some troopers whose own were worn out. [Illustration: FIG. 4.--My Buggy on the veldt at Bloemfontein. (Photo by Mr. Bowlby)] With regard to the general health of the troops as subjects of surgical wounds, I suppose a better class of patient could scarcely be found. The men were young, sound, well set and nourished, and hard and fit from exercise in the open air. Beyond this, in spite of the scarcity of vegetables, a certain amount of fruit, rations of jam, and lime juice made any sign of scurvy a rare occurrence--I never saw a case during the whole of my wanderings. The meat was good, especially in the early part of the campaign, when it was for the most part brought from Australia and New Zealand, and we enjoyed the two collateral advantages of getting plenty of the ice which had been used for the preservation of the meat, in the camps, and the still greater one of having no butchers' offal to need destruction or prove a source of danger. When bread was to be got it was fairly good, and the biscuit was at all times excellent. Except on the advance from Modder River to Bloemfontein, as far as I could judge, no large bodies of the men ever really suffered from shortness of food, and then only for a few days. Drink was a more serious problem: in the early days beer was to be got at the canteens, but with the increase of numbers and difficulties of transport this ceased to be the case, and water was the sole fluid available. This was often muddy, and the soldiers would take very little care what they drank unless under constant supervision; hence a great quantity of very undesirable water was drunk. None the less I think the water was more often the cause of sand diarrhoea than of enteric fever. A large quantity of fluid was by no means a necessity if the men would only have exercised some self-control. During the first week I spent at Orange River, I drank lime juice and water all day, but after that time, by a very slight amount of determination, I thoroughly broke myself of the habit, and drank at meal-times only. Most of the men however emptied their water-bottles during the first hour of the march, and the rest of the day endured agony, seizing the first opportunity of drinking any filthy water they met with. When, for instance, we camped near a vlei, and the General took the greatest care that the mules and horses should be watered at one spot only, in order to preserve the cleanliness of the rest of the pool, the men would often go and fill their water-bottles amongst the animals' feet rather than take the trouble to walk the few necessary yards round. In such particulars they needed constant supervision. The climate on the western side was a great element no doubt both in the general healthiness of the men and in the general good results seen in the healing of wounds. The days were often hot; thus even in November at Orange River the thermometer registered 115°F. in the single bell tents, but on the other hand the nights were cool and refreshing. The air was very pure and exceedingly dry, while the constant sunshine not only kept up the spirits, but also proved the most efficient disinfector of any ground fouled to less than a serious extent. Dust was our principal bugbear; and when a camp had been settled for a few days, flies; both of these evils increasing rapidly as the stay on any one spot was prolonged. My personal experience of rain was small, but I was twice in camp, once at Orange River and once at Bloemfontein, when very heavy rain fell, and this was sufficient to make the camps terribly uncomfortable for a few days. Under these conditions, as might be expected, until the outbreak of enteric fever the health of the men was remarkably good, minor ailments alone prevailing. One of the most troublesome of these was diarrhoea, which gained the appellation of 'the Modders,' already a classical name as far as South Africa is concerned. This most frequently, I think, depended on errors of diet, combined with the swallowing of a large amount of sand with the food as dust, and in the water drunk. Cases of severe dysentery, however, were also not very uncommon. Rheumatic pains were a common ailment, which, considering the dryness of the atmosphere, would hardly have been expected. Continued fever of a somewhat special type was not uncommon, and was sometimes spoken of under the name of the district, sometimes as veldt fever--of this I will say nothing, as others better fitted to point out its peculiarities will no doubt deal with it. Enteric fever, our chief scourge, I will pass over for the same reason. I might, however, remark from the point of view of one not very experienced in this disease, that in a large number of the fatal cases I happened to see, the actual cause of death seemed to me to be septicæmia from absorption from the mouth. The mouths were unusually bad, even allowing for the often insufficient cleansing that was able to be carried out, and I was inclined to attribute these in some degree to the dryness of the atmosphere, which very quickly and effectively dried up the mucous membrane of the mouth in patients not breathing through the nose, and encouraged the formation of large cracks. Pneumonia was rare, and this was rendered the more striking from the comparatively large number of men who contracted the disease on board ship on the voyage out from England. As will be gathered from the above, medical disease seldom called for the aid of the surgeon. Abdominal section was occasionally considered in cases of perforation in enteric fever, and was, I believe, a few times performed, but as far as I know without success. It was also proposed to treat some of the severe dysentery cases by colotomy, but I never saw the method tried. As far as I was concerned I never met with a case of either disease I thought suitable for the treatment. I saw one case in which an abscess of the liver had followed an attack of enteric, which had been successfully treated by incision, and a few cases of tropical abscess which probably came into the country were also subjected to operation. Some cases of appendicitis, as would be expected, also needed surgical treatment. In a few instances empyema followed influenza, and a few cases of mastoid suppuration had to be dealt with. Of surgical diseases the one most special to the campaign, although not of great importance, was the veldt sore. This was a small localised suppuration most common on the hands and neck, but sometimes invading the whole trunk, more particularly the lower extremities however, when the covered parts of the body were attacked. The sores were no doubt the result of local infections; they reminded me most of the sores seen on the hands of plasterers, and I think there is no doubt the dust was responsible for them. I think piles were somewhat more prevalent than they should have been among the men, but this was probably dependent on the strain involved in defæcation in the squatting position, since the soldiers were for the most part regularly attentive to the calls of nature. I saw a good many cases of lightning stroke, and some were fatal. Sunstroke was not common, and, considering the heat, it was very remarkable how little the men suffered from this condition. This was no doubt in part attributable to the absence of the possibility of getting alcoholic drinks, but it is not common for any one in South Africa to suffer in this way, probably as a result of the continuous nature of the sunshine. In spite of the labours of hospital surgeons at home, it was rather instructive to see the number of men who suffered with hernia, varicocele, and varicose veins to a sufficient degree to necessitate going to the base. The experience quite sufficed to explain the trouble which is taken to prevent men with these complaints entering the service. GENERAL CONSIDERATION OF THE NUMBER OF MEN KILLED AND WOUNDED I will now pass to the question of the proportionate frequency with which the men were killed or wounded during the present campaign. I propose to take only one series of battles, with which I was personally acquainted throughout, to illustrate this point. This seems the more satisfactory course to follow, since the number of casualties is still undergoing continuous gradual increase, and besides this the warfare has assumed a peculiar and irregular form, statistics from which scarcely possess general application. The battles included, those of the first Kimberley Relief Force, were fought under fair average conditions as to the nature of the ground. In the first two the defending enemy occupied heights, in the two following the ground advanced over by our men was comparatively even; thus at Modder River there was only a gradual slope upwards, and at Magersfontein the advanced trenches of the Boers were only slightly above the level of the ground over which the advance was made. At the same time, at the latter battle a great number of the Boers engaged were on the sides of the hill well above the advanced trenches. In no case were the Boers in such a position as to have to fire upwards, to them a considerable advantage. It must also be noted that throughout the Boers were able to rest their rifles; hence the fire should have been at any rate of an average degree of accuracy. In the advances of our own men, anthills and stones were practically the only cover to be obtained, and little or no help was given by variations in the general surface. All these points seem to favour a large proportional number of hits on the part of the riflemen. I very much regret that I am unable to say what was the proportional number of shell wounds among the men hit, but I can say with some confidence that among the wounded it was not as great as ten per cent. I should be inclined to place it as low as five per cent. Again, I cannot fix the proportionate occurrence of wounds from bullets of large calibre such as the Martini-Henry, but this was certainly not large. I think if ten per cent. is deducted to represent the number of hits from either of these forms of projectile, that we may fairly assume the remaining 90 per cent. of the wounds to have been produced by bullets of small calibre. The numbers of the opposing forces were probably fairly even. Taking all these circumstances together, and bearing in mind that our army was always in the position of having to make frontal attacks on men well protected in strong positions, I think it must be allowed that a fair idea should be possible of the effectiveness of the modern weapons. Only one circumstance, one inseparable from any fighting with the Boers, seems to affect the numbers in an important manner. This consists in the fact that the Boer rarely fights to the bitter end, hence the greater proportion of his hits are obtained at long distances. TABLE I +---------------------+--------+------+-------+-------+-----+-------------+ | | Number | | | | |Percentage of| | | of | | | | | killed and | | | troops |Killed|Wounded|Missing|Total| wounded to | | | engaged| | | | |number of men| | | | | | | | engaged | +---------------------+--------+------+-------+-------+-----+-------------+ |_Belmont:_ | | | | | | | | Officers | 297 | 3 | 23 | 0 | 26 | 8.75 | | Non.-com. officers | | | | | | | | and men | 8,396 | 55 | 206 | 4 | 265 | 3.15 | | +--------+------+-------+-------+-----+-------------+ | Total | 8,693 | 58 | 229 | 4 | 291 | 3.34 | | | | | | | | | |_Graspan:_ | | | | | | | | Officers | 326 | 3 | 7 | 0 | 10 | 3.06 | | Non.-com. officers | | | | | | | | and men | 8,213 | 18 | 163 | 7 | 188 | 2.29 | | +--------+------+-------+-------+-----+-------------+ | Total | 8,539 | 21 | 170 | 7 | 198 | 2.31 | | | | | | | | | |_Modder River:_ | | | | | | | | Officers | 335 | 3 | 19 | 0 | 22 | 6.56 | | Non.-com. officers | | | | | | | | and men | 9,856 | 67 | 377 | 18 | 462 | 4.68 | | +--------+------+-------+-------+-----+-------------+ | Total | 10,191 | 70 | 396 | 18 | 484 | 4.74 | | | | | | | | | |_Magersfontein:_ | | | | | | | | Officers | 379 | 18 | 48 | 2 | 68 | 17.94 | | Non.-com. officers | | | | | | | | and men | 11,068 | 148 | 669 | 101 | 918 | 8.29 | | +--------+------+-------+-------+-----+-------------+ | Total[1] | 11,447 | 166 | 717 | 103 | 986 | 8.43 | +---------------------+--------+------+-------+-------+-----+-------------+ Table I. gives the number of men engaged, and also that of the killed and wounded at each of four battles. Table III. shows for comparison the relative number of killed and wounded in some former campaigns while older forms of weapon were in use. With regard to the numbers in Tables I. and II. it should be at once said that they are only to be regarded as approximate, since they do not exactly tally with those officially reported in the 'Times' at a later date. Sources of error may, however, have crept into both, and as there is little difference in the gross numbers, I have preferred to retain the series compiled by Major Burtchaell, R.A.M.C., as Table II. contains interesting information as to the proportionate number of men who died during the first 48 hours, after being wounded. TABLE II SHOWING PROPORTION OF MORTALITY AMONGST MEN HIT, (_a_) ON THE FIELD, (_b_) DURING THE FIRST FORTY-EIGHT HOURS ---------------------+-------+------+------+------+-------+---------------- |Number |Total | | Died | | Percentage | of |number| |within| | mortality -- |troops |of men|Killed|forty-| Total +-------+-------- |engaged| hit | |eight | |To men |To force | | | |hours | | hit |employed ---------------------+-------+------+------+------+-------+-------+-------- _Belmont_: | | | | | | | Officers | 297 | 26 | 3 | 3 | 6 | 23 | 2.02 Non.-com. officers | | | | | | | and men | 8,396 | 265 | 55 | 8 | 63 | 23.77 | 0.75 +-------+------+------+------+-------+-------+-------- Total | 8,693 | 291 | 58 | 11 | 69 | 23.71 | 0.79 | | | | | | | _Graspan_: | | | | | | | Officers | 326 | 10 | 3 | 1 | 4 | 40[2] | 1.22 Non.-com. officers | | | | | | | and men | 8,213 | 188 | 18 | 3 | 21 | 11.17 | 0.25 +-------+------+------+------+-------+-------+-------- Total | 8,539 | 198 | 21 | 4 | 25 | 12.62 | 0.29 | | | | | | | _Modder River_: | | | | | | | Officers | 335 | 22 | 3 | 1 | 4 | 18.18 | 1.19 Non.-com. officers | | | | | | | and men | 9,856 | 462 | 67 | 9 | 76 | 16.45 | 0.77 +-------+------+------+------+-------+-------+-------- Total |10,191 | 484 | 70 | 10 | 80 | 16.53 | 0.78 | | | | | | | _Magersfontein_: | | | | | | | Officers | 379 | 68 | 18 | 4 | 22 | 32.35 | 5.80 Non.-com. officers | | | | | | | and men |11,068 | 918 | 148 | 20 | 168 | 18.30 | 1.51 +-------+------+------+------+-------+-------+-------- Total |11,447 | 986 | 166 | 24 | 190 | 19.26 | 1.66 ---------------------+-------+------+------+------+-------+-------+-------- The high death rate among the officers will at once arrest attention, but this has been noticed in other campaigns, particularly in the Franco-German war. It is mainly attributable to the circumstance that the officers, as leading, are always in the front and most exposed position. I much doubt whether at the end of the campaign the entire abandonment of distinctive badges will be found to have had any very important result in decreasing the relative number of casualties as between officers and men. At close quarters distinctive uniform is no doubt a danger, but at the common ranges of 1,000 yards and upwards the enemy's fire is rather directed to cover a zone than to pick out individuals. The especially high mortality among the officers at the battle of Graspan was attributable to the casualties among the naval officers, and the men of the brigade suffered most severely also. It will be noted that the most expensive battles were those of Belmont and Magersfontein. If the numbers of the men actually taking part in the fighting in these battles as given in Table I. are massed, we get an approximate total of 12,420.[3] Of this number, 1,959 or 15.06 per cent. were reported as killed, wounded, or missing. Thus: killed, 315 or 2.53 per cent.; wounded, 1,512 or 12.17 per cent.; missing, 132 or 1.06 per cent. Reference to Table III. shows that these percentages almost exactly correspond with those obtaining in the entire Crimean campaign, and are greater than those observed in the German army during the entire Franco-German campaign. The mortality statistics given in Table II. are of great interest, since to those dying on the field are added all men dying within the first 48 hours in the Field hospitals. From the surgical point of view these men all received mortal injury, and are therefore properly included among the fatalities. Their inclusion, moreover, makes an appreciable difference in the percentage proportion of mortal injuries to wounds. Thus, if the numbers are massed (omitting the 'missing'), we find that in the four battles 1,827 men were hit, of whom 315, or 17.24 per cent., were killed. Among the wounded carried off the field, however, 49 received mortal injuries, and if these are added to the 315, we find that the proportion of mortal injuries reaches 19.92 per cent. TABLE III[4] +-----------------------+---------+---------+--------+---------+----------+ | | | | 1871. | 1877. | 1899. | | | 1815. | 1854. | Franco-| Russo- | Kimberley| | | Waterloo| Crimean | German | Turkish | Relief | | | (English| War | War | War | Force | | | troops) | (English| (German| (Russian| (English | | | | troops) | troops)| troops) | troops) | +-----------------------+---------+---------+--------+---------+----------+ | Number of troops | | | | | | | engaged | 36,240 | 97,864 | 887,876| 300,000 | 15,748 | | | | | | | | | Number of killed | 1,759 | 2,775 | 17,570| 32,780 | 315 | | Percentage | 4.85 | 2.81 | 1.97| 10.92 | 2 | | | | | | | | | Number of wounded | 5,892 | 12,094 | 96,189| 71,268 | 1,512 | | Percentage | 16.25 | 12.35 | 10.83| 23.75 | 9.60 | | | | | | | | | Number of missing | 807 | -- | 4,009| -- | 132 | | Percentage | 2.19 | -- | 0.45| -- | .83 | +-----------------------+---------+---------+--------+---------+----------+ | Total killed, | | | | | | | wounded, and missing | 8,458 | 14,849 | 117,768| 104,050 | 1,959 | | Percentage | 23.31 | 15.17 | 13.26| 34.68 | 12.43 | +-----------------------+---------+---------+--------+---------+----------+ The proportion of men killed to those wounded was as follows: killed 315, wounded 1,512, or 1 to 4.8. If we add to the men killed on the field of battle the 49 dying in the next 48 hours, the proportion of fatalities is increased to 1 to 4.15. The higher of these proportions is certainly the surgically correct one. With regard to the general accuracy of the numbers given above, a comparison of those published for the campaign up to September 15, 1900, is of value, as the two series substantially tally. Thus, up to that date, 17,072 men were hit, and of these 2,998 were killed. The proportion killed to wounded was therefore 1 to 4.69. If it be borne in mind that of the wounded men included in Table I., 1.5 per cent. died later in the Base hospitals, the percentages are almost identical. Table III. is inserted with a view to instituting a comparison between the number of casualties in the present and earlier campaigns. For the purposes of this table it is necessary to take the approximate number of men at Lord Methuen's disposal, irrespective of their active participation in the fighting. The result of this addition to the total is to show that the percentage of men killed and wounded was slightly lower than in the Crimean war, and nearly corresponded with that observed in the Franco-German campaign. As it has been shown that our numbers correspond in general with those of the whole war up to September 15, 1900, there can be little doubt that the same ratios will be maintained to the close of the campaign. On the face of the numbers, therefore, there is little ground for assuming that the change in the nature of the weapons has materially influenced the deadliness of warfare at all. This is capable of explanation on the ground that in the Crimea the battles were fought at much closer quarters, and hence the weapons of the time were as effective, or more so, than the present ones. That this increased distance between the combatants will always counterbalance the increased deadliness of the weapons in the future is more than probable, since the range of effectiveness has been increased both in rifle and in artillery fire. In the present campaign the effect of the latter was very noticeable, since the Boers were, as a rule, quickly displaced by shell fire, unless they were in especially favourable positions, and this although no great number of men was hit by the projectiles. Under these circumstances, except on some occasions, neither side derived all the advantage from the increased shooting powers of their rifles which might have been expected. To a lesser degree this will probably always be the case in the future. In connection with these remarks, however, I would point to column 4 of Table III., as showing how difficult it is to draw definite deductions from any particular set of numbers alone. This column shows that in the Russo-Turkish War of 1877 all the percentages were practically doubled or more, and in the case of the number of men killed on the field of battle, the number was nearly five times as great as either in the Crimea or the present campaign. The explanation here depends on the race of men and their tenacity in resistance alone. In the case of either nation death in battle is little feared, and slight inclination to avoid it exists. When the theory of war held by the Boer--_i.e._ going out to shoot an enemy without incurring risk of being yourself shot--is borne in mind, the special circumstances attending the present campaign are sufficiently obvious to need little further remark. A future campaign in which the combatants are as equally well armed, but each side stands to the last, will probably give very different results. It is unfortunate that no details can be given as to the influence of range in altering the relative numbers of killed to wounded. It may be stated, however, that in no instance did the percentage of killed to wounded reach 25 per cent. At the battle of Magersfontein it amounted to 19.26 per cent., at Colenso to 17.97 per cent., and at both these engagements there is little doubt that a considerable number of the men were hit within a distance of 1,000 yards. When the distances were very short the injuries were frequently multiple; and this character was a more common source of danger than increase of severity in the individual wounds received at a short range. A short consideration of the circumstances especially influencing the ultimate mortality amongst the wounded subsequent to the reception of the injury is here necessary, although I shall be obliged to make my remarks as short as possible. The subject is best treated of under the two headings of Transport and Hospital Accommodation. _Transport._--The importance of transport is felt from the moment of the injury till the time of arrival of the patient in the mother country. To the surgeon it is of the same vital importance as the carrying of food for the troops is to the combatant general. (_a_) Removal of the wounded from the field of battle. My experience was opposed to hurried action in this matter, although it is necessary to gather up the wounded before nightfall if possible. As a rule wounded men should not be removed from the field of battle under fire, at any rate when the troops are in open order at a range of 1,000 yards or more. I saw several instances in which mortal wounds were incurred by previously wounded men or their bearers during the process of removal, while it was astonishing how many scattered wounded men could lie out under a heavy fire and escape by the doctrine of chances. The erect position and small group necessary to bear off a wounded man at once draws a concentrated fire, if fighting is still proceeding. As to the best and quickest method of removing the patients to the first dressing station, there were few occasions when this was not more satisfactorily done by bearers with stretchers than by wagons. The movement was more easy to the wounded men, and, as a rule, time was saved. Over rough ground the wagons travel slowly, and patients with only provisional splints were shaken undesirably. A stretcher party in my experience easily outstripped the wagon unless a road or very smooth veldt existed. A larger number of men is of course required, but I take it that on the occasion of a great war men are both more easily obtained and fed than are transport animals. From what I have been able to learn, both the Indian dhoolie-bearers and the hastily recruited Colonial bearer companies were most successful in the removal of the large number of wounded men from the field of Colenso. I had several opportunities of comparing the two methods on a smaller scale during the fighting in Orange River Colony, and felt very strongly in favour of the stretcher parties. For removal of patients from one part of a hospital to another, or sometimes in loading trains, &c., great economy of men, and increased comfort to the patients, may be attained by the use of some form of ambulance trolly. I append an illustration of what seemed to me the simplest and best I came across among several in use in South Africa. The description beneath is by Major McCormack, R.A.M.C., its inventor (fig. 5). When wagons were necessary or preferable, the Indian Tongas (fig. 6), presented by Mr. Dhanjibhoy, were most useful; they carried two men lying down, the same number as the big service wagon, and were drawn by two ponies only. Although somewhat highly springed, the vehicle is so well arranged and padded, that the occupants are seldom hurt by striking against the sides with rough jolting, unless quite helpless. I occasionally made long journeys in this vehicle with much comfort. [Illustration: FIG. 5.--The McCormack-Brook Wheeled Stretcher Carriage. It consists of an under-carriage built up of two light wheels with steel spokes and rims with rubber tyres and ball bearings; on the axle are two light elliptic springs, to which is attached a transverse seat for the stretcher-carrier proper. This is securely bolted on to the seat, and consists of two pieces of hard wood, suitably worked, and forming an angle frame. On the bottom side the stretcher poles rest, and the sides of the L formed by the carrier proper prevent most effectually any jerking or turning of the stretcher when once it has been laid in the carrier. The carrier is about thirty inches long, but can be increased to any length desired. It has been found that this length is admirably suited for all purposes. To prevent the stretcher from any lateral or upward movement, two buttons with tightening screws are attached to the top of the carrier on each side. When the stretcher is laid on the carrier the screws are tightened and the stretcher is held rigid. Two iron supports are provided, one at each end and on opposite sides of the carrier. These are lowered when it is desired either to place the stretcher on the carriage or remove it therefrom, which can be effected in a second. The carriage meanwhile remains perfectly still. When the carriage is in motion the iron supports are turned up, and lie along the respective sides of the carrier, where each rests in a small clip. The great object of this stretcher carriage has been to obtain mobility, strength, and lightness combined with efficiency and a ready and easy means of transport for sick and wounded, no matter where a patient has to be transported from. The loaded stretcher and wheeled carriage can be readily handled by one man on good roads, and by two men in rough country. The springs prevent any jar being felt by the patient on the stretcher.] (_b_) For the longer journeys to the Field or Stationary hospitals, the service wagon and other transport vehicles came into use, particularly the South African ox-wagon. [Illustration: FIG. 6--Indian Tonga on the march. (Photo by Mr. Bowlby)] The service wagon (fig. 7) is a heavy four-wheeled vehicle, drawn by ten mules. The good construction of the wagon was amply proved by the manner in which it stood the hard wear and tear of the present campaign. It is, however, very heavy, and in comparison with its size affords very small accommodation. Two lying-down patients and six sitting is its entire capacity. Some modified patterns were in use, notably those with the Irish and Imperial Yeomanry Field Hospitals, capable of carrying four lying-down cases, the men being arranged in two tiers. Major Hale, R.A.M.C., made a very successful trek from Rhenoster to Kroonstadt with some of these, carrying twice the regulation number of lying-down cases in his wagons. Some modification in the mode of fixation is, however, necessary to increase the security of the stretchers of the upper series. A really satisfactory wagon, combining both strength and comfort, still remains to be devised. [Illustration: FIG. 7.--Service Ambulance Wagon, the six front mules removed. (Photo by Mr. C. S. Wallace)] During the later stages of the campaign, a very large number of patients were transported by the South African ox- or mule- (buck) wagons. Although not of prepossessing appearance, and unprovided with any sort of springs, these vehicles were far from unsatisfactory. The ox-wagon consists of a long simple platform, 19 ft. 2 in. in length, 4 ft. 6 in. in width, from the sides of which a slanting board rises over the wheels for the posterior two-thirds. These bulwarks increase the actual width to 6 ft. 6 in., which corresponds with the gross width occupied by the wheels. One third is covered by a small hood 5 ft. 6 in. in height erected on wooden stave hoops. The latter was often absent in transport wagons. The two hind wheels are large, the fore somewhat smaller. They are attached to very heavy wooden cross-beams bearing the axles, and the two beams are connected by a longitudinal bar, continuous with the düssel boom or pole. This latter bar is in two sections, the connection of which allows considerable play in the long axis and serves to break the jolts occurring when either pair of wheels passes over uneven spots on the ground. When some sacks of oats or hay were spread over the floor the wounded men travelled comparatively comfortably in these wagons, the great distance between the fore and hind wheels tending to minimise the jolting. The principal objection to them was the slow pace of the oxen, and the fact that to obtain the greatest amount of work from these animals a major part of the journey must be performed during the night. The ox-wagon carries, with comfort, four lying-down cases on stretchers, or six without stretchers; or twenty sitting-up cases. [Illustration: FIG. 8.--South African Wagon, loaded with patients, and mule transport. (Photo by Mr. C. S. Wallace)] The mule- or buck-wagon, which is of the same class but smaller, can only accommodate two stretchers, four lying-down men without stretchers, or 12-14 sitting-up cases. As a rule, the wagons were loaded with recumbent cases in the centre, while more slightly wounded men sat around, and were able to give help to those lying down when needed. The wagons can be covered with canvas throughout. The steady even pace of the oxen is a great advantage, and I was often surprised to see how well men bore transport in these wagons, who seemed utterly unfit to be moved had it not been an absolute necessity. A very large number of the wounded from Paardeberg Drift were transported to Modder River in them. One other advantage of these wagons, the possibility of converting them into an excellent laager, is not to be underrated. Any one who saw the comfortable encampment which a naval contingent on the march made by massing the wagons with intervals covered by macintosh sheets, could at once appreciate their capabilities for a long trek. Traction engines were, as far as I know, never employed as a means of transporting the sick. The tendency of these heavy machines to stick in the mud and to break down bridges is so well known that it hardly needs mention. Putting these disadvantages on one side, with a supply of fuel ensured, and such roads as are afforded by a civilised country, a great future is probably before this means of transport for the wounded. A large number of patients might be carried at an even pace, and the camps would be saved all the trouble and worry of the transport animals. _Trains._--In many cases in Natal, and in a few instances on the western side, the wounded men were able to be transferred from the first dressing station directly into the trains. Space will not allow me to describe any of those in use, but the accompanying illustration shows the general arrangement of the beds in Nos. 2 and 3 trains (fig. 9). The carriages were converted from ordinary bogie wagons of the Cape Government Railway stock under the supervision of Colonel Supple, R.A.M.C., P.M.O. of the Base at Cape Town. Each train was provided with accommodation for two medical officers, two nursing Sisters, orderlies, a kitchen, and a dispensary, and each carried some 120 patients. The trains were under the charge of Major Russell, R.A.M.C., and Dr. Boswell (and later other civilian medical officers) and of Captain Fleming, R.A.M.C., D.S.O., and Mr. Waters, and carried many thousand patients from all parts of the country to the Base and Station hospitals. They were most admirably worked, and seemed to offer little scope for improvement except in minor details. To them much of the success in the treatment of the wounded who had to traverse the immense distances incident to South Africa must be attributed. I made many pleasant journeys in each of them. Later, two additional trains, Nos. 4 and 5, of a similar nature, were added. Two trains, No. 1, and the Princess Christian train, which I was not fortunate enough to see, performed similar duties for Natal. [Illustration: FIG. 9.--Interior of one of the Wagons of No. 2 Hospital Train] _Hospital Ships._--These were numerous and some especially well arranged. Fig. 10 is of the 'Simla,' a P. & O. vessel which was admirably adapted to the requirements of a hospital ship. On her main deck some 250 patients were accommodated in a series of wards all on the same level, which much lightened the difficulties of service usually experienced. During the present campaign the abundance of transport vessels rendered the transhipment of patients to England a matter of comparative ease, and good vessels were always available. Considering the constant transhipment of invalids from India and our other colonial possessions, it would seem advisable that, in place of having to hurriedly improvise hospital ships, the Government should possess two or three hospital ships of the 'Simla' type. It is true this would deprive our naval transport officers of a duty which in this war was performed with extraordinary celerity and success; thus the 'Simla' was fitted in seven days, and sailed with a cargo of invalids ten days after her arrival at Durban; but on the other hand it would ensure that really suitable vessels were always provided. [Illustration: FIG. 10.--P. & O. Hospital Ship 'Simla' in Durban Harbour] To give some idea of the amount of work contingent on the transport of wounded men from an army of some 15,000, fighting its way against continued opposition, I will quote the approximate number of men moved during Lord Methuen's advance from Orange River to Magersfontein. (The number of men actually present at each battle is shown in Table I., p. 12.) Belmont, the first battle, was fought on November 23. _November 24._--No. 2 hospital train removed 152 cases to the Stationary Field hospitals at Orange River, then returned and loaded up with 130 more. Some of the most severe cases in the latter were detrained at Orange River, and the remainder were taken direct to Wynberg (591-1/2 miles). The division marched, and the battle of Graspan was fought during the day. _November 26._--A train of specially constructed trucks brought 90 of the less severe cases, including 20 Boers, to Orange River. _November 27._--The division marched, and in the morning No. 3 hospital train removed 80 severe cases from the Field hospitals direct to Wynberg. _November 28._--Battle of Modder River. _November 29._--339 patients, including a few sick, and some wounded Boers, were sent down to Orange River in open trucks with impromptu shelters made with rifles and blankets. Later, 97 severe cases were sent down in ordinary carriages, of which some had doors sawn out to admit lying-down patients. _December 10._--The division marched, and on the next day the battle of Magersfontein was fought. _December 11._--Nos. 2 and 3 trains were loaded up during the night and early morning of the 12th, in part from the Field hospitals, in part directly from the Ambulance wagons. During the day of the 12th, No. 3 train made three journeys to Orange River, and No. 2 was sent direct to Wynberg. In all some 800 patients needed transport; they were picked up by 10 ambulance wagons and 5 buck wagons for slighter cases and the two bearer companies sent out from Modder River. On the 12th Lord Methuen sent out a number of bearers with stretchers, and at 12 noon all the wounded were collected, but many had lain out through the night. The bearers had to retire under a shell fire kept up by the Boers as long as our army was within range of their position. Four Field hospitals were present, but only that of the IX. Brigade at Modder River was so situated as to be of general use. This hospital, under the command of Major Harris, R.A.M.C., did an immense amount of work most expeditiously and with great success. The nature of the advance on Kimberley necessitated the evacuation of the Field hospitals with extreme promptitude, as the troops were in constant action, and the arrangements for this were carried out with great success by Colonel Townsend, the P.M.O. of the First Division. The amount of fighting far exceeded anything that had been expected, and the Stationary hospitals on the lines of communication at Orange River and De Aar were unable to cope with the number of severe cases thrown on their hands, with the constant possibility of new arrivals. Hence a number of severe cases had to be sent direct to Wynberg. This experience strongly illustrated the necessity of possessing Stationary hospitals of greater mobility and a higher degree of equipment than the service at present possesses. In these a large number of severe cases could have been retained, and only the slighter ones exposed to the fatigue and general disadvantage of transport. In South Africa very special difficulties existed in the length of the line of communication, the single line of rails, and the absence of any source of supply within 500 to 600 miles; but in any other country mobile Stationary hospitals, although more easily equipped, would be equally valuable. The difficulties of transport experienced in the advance of the Kimberley Relief Force were many times multiplied in that upon Bloemfontein, since the whole of the severely wounded men had to be sent back thirty to forty miles to the railway. The ambulance accommodation on the occasion of this march, although, if untouched, proportionately smaller than that possessed by Lord Methuen, was reduced to one-fifth to meet the exigencies of warfare. Beyond this the equipment transport of the Field hospitals was reduced from four ox-wagons to two, and the Scotch cart was cut off, only two ox-wagons and the two water-carts being allowed. This greatly hampered the Field hospitals on the march, and when they arrived at Bloemfontein and had to undertake the work of Stationary hospitals, their efficiency was seriously impaired. Again, on the advance from Bloemfontein to Kroonstadt many of the Field hospitals were unable to accompany their respective divisions, not alone on account of the number of patients remaining in them, but also because the mule transport had been otherwise employed for military purposes. The transport of the ambulances and hospitals stands in a very special position. As far as my experience went, neither ambulances nor hospitals were ever taken or retained by the Boers, and consequently the transport animals originally devoted to this purpose should have been held sacred to it. _Hospitals._--Accommodation for the wounded was provided under canvas in the Field hospitals, also in the large General hospitals. Beyond this iron huts were erected in many of the Base and Station hospitals. At Capetown, Maritzburg, and Ladysmith barrack huts were modified and equipped as hospitals, and in towns such as Bloemfontein, Kimberley, and Johannesburg large civil hospitals were at our disposal. Beyond these sources of accommodation, churches, schools, public institutions, and private houses were made use of in the smaller towns. As to the broad question of canvas _v._ buildings, experience amply showed that in a climate such as is possessed by South Africa, canvas affords the greater advantages. The hospitals are more mobile, more readily extended, and the more healthy. Except under unusual conditions of rain and dust, the patients did excellently in the tents. Rain and dust were occasionally most troublesome, especially when combined with wind. I once saw a whole hospital, fortunately unoccupied, levelled to the ground in the course of some twenty minutes. Under such circumstances iron huts present advantages, and were on many occasions utilised with much success. They are readily erected, and it would have been a considerable improvement if a number of them had been ready for use at the earliest part of the campaign. Except in the matter of weight, they possess in a considerable degree the advantage of mobility possessed by canvas, and in addition they offer much more protection from the weather. On the other hand, they are more liable to become unhealthy from prolonged use. Churches and public institutions were mainly troublesome from the necessity of having to improvise sanitary arrangements, and sometimes the disadvantage of the collection of a large number of men in one chamber could not be avoided. None the less I cannot look back without admiration on the temporary hospitals established in the Raadzaal at Bloemfontein, and the Irish hospital in the Palace of Justice in Pretoria. The State schools in the smaller towns of the Orange River Colony also afforded excellent accommodation as small temporary hospitals. Private houses, possessing the disadvantages of ill-adapted construction and the necessity of a considerably increased staff to work them, were on the whole little used as hospitals. The scattered farmhouses occasionally afforded shelter to very severely wounded men. In most of the country I traversed, however, the farms were so wide apart as to be of little use in this respect; and again, under the special circumstances, patients left in them might have to be abandoned to the enemy. The chief interest during the campaign centred in the working of the Field and General hospitals. Two types of Field hospital were employed, one the Home, the other the Indian. The latter differs from the Home in that in it the bearer company is attached and consists of Indian natives, and that the hospital is separable into four sections in place of two only. The amalgamation of the Field hospital and bearer company into one unit is much to be desired in the Home service, both for economy of working and the more equal distribution of duties to the medical officers engaged. Again the divisibility of the hospital into four sections is also an advantage. It allows of the advance or the leaving of sections, in the case of either small expeditions or the presence of a number of severely wounded men unfit to travel. As far as I could judge, it necessitates very small addition to the present equipment, and is in every way desirable. As to the working of the Field hospitals in the present campaign, it was universally acknowledged to possess a very high degree of excellence. The equipment, with small exceptions, proved equal to the demands made upon it. The mobility of the camps was proved again and again, and the rules governing their administration evidenced by their effectiveness the care and experience which have been bestowed on the organisation of the hospitals. It is difficult for any one who has not had an opportunity of observing the actual amount of work performed in the Field hospitals either to appreciate the storm and stress following an important engagement when the wounded men are first brought in, or the demands that are made on the powers of the medical officers in charge. To a civilian the first feeling is one of impotence, followed by an attempt to see no further than the case under immediate observation, and to nurture the conviction that the work is to be got through if it is only stuck to. I gathered that this first impression was absent in the minds of the officers in charge of the Field hospitals, as work commenced at once, and was carried on without intermission during the persistence of daylight, in the winter often by the aid of lanterns, and eventually the huge task was accomplished. In early days at Orange River work commenced at 4 A.M., and was steadily continued until 6 P.M. or later, and this state of things persisted sometimes for many days together. The officers of the Field hospitals, the bearer companies, and those doing regimental duty carried out their duties with a calmness and efficiency which not only impressed observers like myself, but also excited the admiration of our German colleagues sent by their government to observe the working of the British system. I saw on several occasions the German and Dutch ambulances, and was much struck by the excellence of their equipment. In some details there was much to be learned from them, especially in the matter of appliances, dressings, and instruments. The Dutch ambulance I saw at Brandfort had a complete installation of acetylene gas, which was carried, gasometer and all, in one Scotch cart. They were, however, really designed to fill the combined position of our Field, Stationary, and General hospitals, and when it became necessary for them to move about frequently, the inferior mobility they possessed in comparison with our own Field hospitals was at once demonstrated. The large General hospitals of 500 beds were a great feature in the campaign. Although designed and organised some time since, the present was the first occasion on which they have come into general use, and they may be said to have actually been on trial. The organisation of these hospitals proved itself excellent, and in the case of the best of them left little to be desired. In some cases the accommodation was temporarily strained enormously, and the number of patients was extended beyond more than three times the regulation limit. The additional patients were then accommodated in marquees and bell tents, according to the nature of their diseases. Under these circumstances the working of the hospitals was difficult, and the officers both of the R.A.M.C. and the civilian surgeons were placed at a great disadvantage. My space does not allow me to give any description of the general arrangement of these hospitals, but I would suggest that a certain number of them should be so modified as to increase their mobility and allow of their being more readily utilised as Stationary hospitals. During the whole campaign it seemed to me that the Stationary hospitals (that is to say, the hospitals necessary to receive patients when the Field hospitals were rapidly evacuated), were those in which some increased uniformity of organisation was most needed. It scarcely needs to be pointed out that this is the most difficult link of the whole hospital chain to be uniformly well organised and equipped. It is needed at short notice, and often for a short period, and it is difficult to maintain a regular staff of officers ready for any emergency without keeping a certain number of men idle. The conversion of Field hospitals to Stationary purposes is undesirable, as the troops move with only a regulation number of the former, which under ordinary circumstances is the minimum that may be necessary. Stationary hospitals as individual units are undesirable for the reasons above given. [Illustration: FIG. 11.--Type of a General Hospital (No. VIII. Bloemfontein) extended by use of bell tents in the distance. (Photo by Mr. C. S. Wallace)] The difficulty might be met by increasing the mobility of a certain number of the General hospitals, by making them divisible into five sections, each of which should be able to move independently, and to the last of which should be attached the heavy part of the equipment, such as the iron huts for operating and X-ray rooms, kitchens, store sheds, &c. The tents might also be lightened by the substitution of the tortoise tent for the service marquee. The tortoise tent is lighter (360 as against 500 lbs.), easily pitched and moved, and holds at least two more patients with ease. The capabilities of this tent were amply proven during its use by the Portland, Irish, and other civil hospitals attached to the army. It withstood wind and weather, the former better than the service marquee. Figs. 11 and 12 show the appearance of camps composed of the two varieties. I must admit a warm preference for the appearance of the service pattern, but I think it is indubitable that the other is the more useful. Given the possibility of division of a General hospital in this manner, single sections could readily be sent up the lines of communication to serve as Stationary hospitals at various points behind the advance of the troops, and on the cessation of active need, the sections could be reunited at any point to form an advanced Base hospital. The sections could be kept in touch throughout by visits from the officer of the lines of communication. This would appear a ready means of providing well-organised Stationary hospitals at short notice, and would save the disadvantage of a definitely separate series. [Illustration: FIG. 12.--Type of Tortoise Tent Hospital. Portland Hospital, Bloemfontein. (Photo by Mr. C. S. Wallace)] Such hospitals might have been used on many occasions when the transport of an entire General hospital was an impossibility. The service, moreover, has some experience in this direction, since at one time No. 3 General Hospital was divided into two definite sections. Bearing in mind the extreme readiness and promptitude with which the officers during the present campaign extended the accommodation of either Field or General hospitals, one of such sections as are proposed might readily be made far more capacious than its regulation number would suggest. My duties being entirely in connection with the service hospitals, I did not become intimately acquainted with any of the volunteer hospitals which did such excellent service, except the Portland, to the staff of which I was indebted for much hospitality and kindness. This hospital was practically of about the capacity proposed for the above-mentioned sections, and the report of its work will no doubt furnish many points of detail as to equipment, &c., which may be useful. The general results of the surgical work done during the campaign were excellent, and taken as a whole the occurrence of any severe form of septic disease was unusual. Pure septicæmia, especially in connection with abdominal injuries, severe head injuries and secondary to acute traumatic osteo-myelitis, was the form most commonly seen. Pyæmia with secondary deposits was uncommon, and often of a somewhat subacute form; thus I saw several patients recover after secondary abscesses had been opened, or the primary focus of infection removed. The only really acute case of joint pyæmia I heard of, developed in connection with a blistered toe followed by cellulitis of the foot. Cutaneous erysipelas I never happened to see, and really acute phlegmonous inflammation was rare. I may mention the occurrence of acute traumatic gangrene in two cases. This developed in each instance with gunshot fracture of the femur; in one amputation was performed, and the process extended upwards on to the abdomen. The cases occurred with the army in the field in the neighbourhood of Thaba-nchu and not in a stationary hospital. Acute traumatic tetanus occurred only in one instance to my knowledge. In this case the primary injury was a shell wound of the thigh, and the patient developed the disease and died within ten days. To the civil surgeon the performance of operations, and the dressing of severe wounds at the front, proved on occasions a somewhat trying ordeal. When operations were necessary in the field, during the daytime, it was often possible to perform them in the open air, provided tolerable protection could be obtained from the sun. A number of cases were so operated upon during the march of the Highland Brigade from Wynberg to Heilbron, and gave excellent results, the patients deriving considerable benefit from the early cleansing and closure of the wounds. [Illustration: FIG. 13.--Tortoise Hospital Tent. Portland Hospital. (Photo by Mr. C. S. Wallace)] In camp, in the Field, or Stationary hospitals, the difficulties were often much greater. The operations were necessarily performed under shelter for reasons of privacy. In the tents the draught carrying the dust from the camp was one of the commonest troubles. The exclusion of dust was impossible, and it not only found its way into open wounds, but permeated bandages with ease. Often when a bandage was removed, an even layer of dust moistened by perspiration covered the whole area included with a coating of mud. Again, in dust storms a similar layer of mud sometimes covered the whole of the exposed parts of the bodies of patients lying on the ground in the tents. It is of some interest to remark with regard to this dust, that Dr. L. L. Jenner lately kindly examined a specimen collected at Modder River after the camp had been more than two months established, and discovered no pathogenic organisms in it. As a period of seven months had elapsed since this dust was collected, the fact is of no practical import, beyond showing that, if such organisms had existed, at any rate they were not of a resistent nature. Insects, particularly common house-flies, were an intolerable pest at times. In a fresh camp they were sometimes not abundant, but after two or three days they multiplied enormously. Not only hospital tents, but living and mess tents, swarmed with them, the canvas appearing positively black at night. Even when dressing a wound, without unceasing passage of the hand across the part, it was impossible to keep them from settling, and during operations the nuisance was much greater. Storms of rain were occasionally as troublesome as, though perhaps less harmful than, those of dust. On one occasion a whole Field hospital was flooded only a few hours after a number of important operations had been performed, and the patients were practically washed out of the tents. It was somewhat remarkable that none of the men suffered any serious ill as a result. At times the temperature was sufficiently high to make either dressing or operating a most exhausting process to the surgeon. The heat of the day was not on the whole so disadvantageous from the point of view of the operator, as the cold of the nights during the winter in Orange River Colony. On one or two occasions serious operations had to be left undone, as it was only possible to consider them in camp, where, as we arrived at night only, the temperature was too low to justify the necessary exposure. Water for use at operations was often a great difficulty. Even at Orange River, where, though muddy, the water was wholesome, it was impossible to get water suitable for operations unless it had previously gone through the complicated processes of precipitation by alum, boiling, and filtration. At Orange River a small room in the house of one of the railway servants was obtained and fitted as a rough operating room by the Royal Engineers. The necessary utensils were provided by Colonel Young, Commissioner of the Red Cross Societies. Here a stock of prepared water was kept for emergencies. The remaining difficulties mainly consisted in those we are familiar with in civil practice, such as the securing of suitable assistance in the handling of instruments and dressing, when the rush of work was very great. At the Base hospitals accommodation for operating in properly equipped rooms obviated many of the difficulties above referred to. In concluding this introduction I should sum up in a few words my experience of the general working of the hospital system during my stay in South Africa. The excellence of the Field hospitals for their purpose has been already alluded to, and, as far as I could ascertain, won the confidence and approval of patients, military commanders, and civilians such as myself. The Stationary hospitals (by which I intend to indicate those receiving the patients directly from the Field hospitals before the establishment of advanced Base hospitals), as already indicated, were not in my opinion so perfectly conceived or organised. The requirements of these are, however, far greater than those of the Field hospitals, and they of all others are dependent on the possession of facilities for rapid transport. In South Africa the difficulties of supplying them were enormous, and no doubt the conditions of the campaign in this, as so many other particulars, were novel and unusual. None the less the experience gained will no doubt be utilised in the future. With regard to the extravagant criticisms levelled at the Field hospitals serving as Stationary hospitals at the time of the early period of the occupation of Bloemfontein, it may be pointed out that the only proper ground for comparison was not between the patients at Bloemfontein and those in hospital at the base, but between the men in hospital and those in the field at that time, since the conditions were equally adverse to both. Besides, it must not be forgotten that a large proportion of the patients, at that time, were really comfortably housed in the Raadzaal and other buildings, the preparation of which entailed a very great amount of both labour and resource. The difficulties experienced at that time will, it is hoped, go far towards securing greater facilities and rights of transport to the Royal Army Medical Corps in the future. As a civilian, one cannot but recognise that the conditions of modern warfare are much altered from those of the past. Prisoners are well cared for and kindly treated, the sick and wounded are respected by both sides, and except in the actual horrors of fighting the condition of the soldier is a happier one. Under these circumstances the limitation of the transport facilities of a department so closely concerned with the well-being of all, and which has been organised on a most moderate scale, must soon become a tradition of the past in civilised armies. As to the efficiency of the organisation of the General hospitals, either at the advanced or actual base, I have already testified. Naturally the working of these hospitals varied with the personal equation of the officer in charge of them, but as a whole the service has every reason to be proud of their success. As far as surgical results are concerned, and with these I had special acquaintance, the success of the hospitals was amply demonstrated. Adverse criticism was not however wanting, and often expressed in the strongest terms by persons totally unacquainted with hospital methods, and apparently unconscious that such excellence as is exhibited in a London hospital is the result of continuous work and development for some centuries, and that such institutions are worked by committees and staffs of permanent constitution. The proportion of female nurses employed in these hospitals underwent steady increase from the commencement of the campaign, and the immense value of the nursing reserve was fully proved. There is no doubt that in Base hospitals the actual nursing should always be entrusted to women. The demands of the campaign necessitated the employment of a large number of civil surgeons in the various hospitals. These gentlemen accommodated themselves with true British aptitude to the conditions under which they were placed, and in all positions their sterling work contributed in no small degree to the success that was attained. One class of hospital still remains for mention. I refer to the improvised hospitals prepared in the Boer towns prior to the British occupation. They were met with in all the smaller towns, and also in the larger ones such as Johannesburg and Pretoria. The Burke hospital in Pretoria, started by a private citizen and his daughter, and the Victoria hospital in Johannesburg, presided over by Dr. and Mrs. Murray, were two of the largest, but each and all deserve due recognition. I am sure that many of our wounded officers and men who were cared for in these hospitals while prisoners in the hands of the Boers, will never lose their sense of gratitude to those inhabitants who spared no effort to render their position as happy as possible under the circumstances; and the existence of these hospitals was no small boon to the service when called upon to take charge of the sick and wounded therein contained. I cannot close this chapter without recognition of the immensity of the task which has fallen on the Royal Army Medical Corps in the treatment of the sick and wounded during the course of the campaign and full appreciation of the manner in which that task has been met. The strain thrown upon this department of the service, originally organised for the needs of an army less than half the magnitude of that eventually taking the field, was incalculably great, and the medical profession may well be proud of the efforts made by its military representatives to do the best possible work under the circumstances. FOOTNOTES: [1] 3,328 men of the IX. Brigade present are not included, as they never came into action. [2] The high mortality was due to deaths amongst the officers of the Naval Brigade. [3] To obtain this total the numbers of killed, wounded, and missing, after the three earlier battles, have been massed, and added to the total number of men known to have taken part in the battle of Magersfontein. The inaccuracy dependent on the fact that some of the men reported as wounded or missing in the earlier battles had already returned to their regiments, and are included in the total of 11,447, must be disregarded. [4] Numbers quoted from Fischer, _Handbuch der Kriegschirurgie_, vol. i. p. 22, 1882. CHAPTER II MODERN MILITARY RIFLES AND THEIR PROJECTILES IN RELATION TO INJURIES PRODUCED BY THEM ON THE HUMAN BODY Before proceeding to the actual description of the wounds inflicted by modern military rifles, it is necessary to prefix a few remarks on the mechanism and mode of production of these injuries. Recent tendency in the construction of military rifles has been in the direction of reduction of bore, and a corresponding one in the calibre of the bullet, the resulting loss of weight in the latter as an element in striking power being compensated for by the attainment of an augmentation of velocity in the flight of the projectile, and a comparatively flat trajectory. Changes in this direction have endowed the weapons with increase both in range and accuracy of fire; while the greater rapidity with which magazine rifles can be discharged and, in consequence of reduction in weight, the greater number of cartridges which can be carried by each man, also form important factors in the possible deadliness of warfare at the present day. None the less the experience of the present campaign has scarcely justified the early prognostications expressed as to a great increase in the number and severity of wounds amongst the combatants.[5] This comparative immunity is to be explained mainly on two grounds. The increased distance which for the most part separated the two bodies of men, a feature no doubt accentuated by the mode of warfare adopted by the Boer, and his strong sense of the folly of close combat on equal terms, tended to efface one of the chief characters, velocity of flight, on the part of the projectile. The want of effectiveness of the small-calibre bullet as an instrument of serious mischief also kept down the mortality. Since the year 1889 the calibre of the bullet in our own army has been reduced from that of the Martini-Henry (.450 in.) to one of .309 in. in the Lee-Metford, and a consequent reduction in weight from 480 to 215 grains. To allow of the satisfactory assumption of the more complicated rifling by the more rapidly projected bullet, the lead core has been ensheathed in a mantle of denser metal. The bullet itself is of an original calibre (.309 in.) somewhat exceeding the bore of the rifle barrel (.303 in.), in which way a species of 'choke' is obtained and deep rifling of the surface ensured. Beyond this the comparative transverse and longitudinal measurements and shape have been altered in order to maintain weight, preserve a proper balance during flight, and increase the power of penetration. These alterations with slight differences in detail embody the general principles that underlie the construction of each of the weapons adopted by European nations. It will be well here to consider the influence of each alteration from the point of view of the surgeon. _Calibre._--The effect of the diminution of calibre is (_a_) to reduce the area of impact of the bullet on the part impinged upon, and hence to lower the degree of resistance offered by the tissues; this to a certain extent tends to neutralise the augmented striking force resulting from the increased velocity of flight. (_b_) To limit considerably the destructive powers of the bullet, as a smaller area of tissue is exposed to its action. (_c_) To allow of the production of very 'neat' injuries and the frequent escape of important structures, also the production of remarkably prolonged subcutaneous tracks in positions where such would be regarded as scarcely possible, and in point of fact were impossible with the older and larger projectiles. _Length._--The comparative increase in length of the bullet is, from the surgical point of view, only of material importance in increasing the weight and therefore the striking power, and in so far as it is a mechanical necessity for the flight of the projectile on an axis parallel to its long diameter, and so tends to ensure impact on the body by the tip of the bullet. This latter is, however, surgically favourable as ensuring a smaller wound. _Weight._--The decrease in weight must be regarded on the whole as altogether to the advantage of the wounded individual, since it cannot be considered to be entirely compensated for by the resulting increased velocity of flight, unless the range of fire is moderately close. _Shape._--The ogival tip and general wedge-like outline, while decreasing the aerial resistance to and increasing the power of penetration possessed by the bullet, at the same time allow the escape of some structures by displacement, while others are saved from complete destruction by undergoing perforation. Beyond this the sharper the tip, the smaller is the area of the body primarily impinged upon, the less the resistance offered to perforation, and to some degree the less the destruction of surrounding tissues. _Increased velocity of flight._--This multiplies the striking force, and compensates in part for decrease in volume and weight of the bullet. It is customary to speak of the velocity as 'initial' and 'remaining.' Initial velocity is the term employed to express the velocity at the time of the escape of the bullet from the barrel; this is also designated as 'muzzle velocity.' 'Remaining velocity' expresses that obtaining during any subsequent portion of the flight of the projectile. The greatest initial velocity is obtained with the use of bullets of the smallest calibre, but this is not of the practical importance which might be assumed, since the remaining velocity of flight of such projectiles falls more rapidly than that of those of slightly greater mass. Thus, although there may be a difference of a hundred metres per second in initial velocity between two rifles of calibres varying from 6.5 to 8 millimetres (.303-.314 in.), at the end of 1,000 metres the discrepancy is greatly reduced, while at 2,000 metres it hardly exists. Under such circumstances the projectile of greater weight and volume, as possessing the greater striking force, is considerably the more formidable of the two. This is the more important if it be allowed, as I believe to be the case, that velocity _per se_ is of no practical import in the case of wounds of the soft parts of the body, which after all form the preponderating number of all gunshot injuries. The effect of the higher degrees of velocity differs, however, with the amount of resistance met with on the part of the body; hence its serious import is well exemplified when parts of the osseous skeleton are implicated, although even here considerable variations exist, dependent upon the structure of that part of the bone actually involved. The most obvious ill effect of injuries from bullets travelling at high rates is seen in the case of the various parts of the nervous system, and here it is undeniable. High velocity and striking force are also responsible for the prolonged course sometimes taken by bullets through the body. The actual degree of velocity, as judged by the range of fire at which an injury is received and the resulting injury, is very hard to estimate on account of the many and varying factors which enter into its determination. The mere recital of some of these will suffice to make this evident. 1. Quality of the individual cartridge employed, as to loading, the materials employed, and their condition. 2. The condition of the rifle as to cleanliness, heating, and the state of the grooves of the barrel. 3. The angle of impact of the bullet with the part injured. 4. Resistance dependent on the weight of the whole body of the man struck, or of an isolated limb. 5. Special peculiarities of build in the individual struck, such as thickness and density of the integument and fasciæ, strength and thickness of the bones, &c. 6. State of tension of the muscles, fasciæ, and ligaments at the moment of impact, and fixity or otherwise of the part of the body struck. 7. The degree of wind, temperature, and hygroscopic conditions of the atmosphere. These form some of the more important points which have to be taken into consideration, in addition to a mere calculation of the actual distance from which a wound has been received from a particular rifle, and taken with the unsatisfactory nature of the evidence as to the latter, which is usually alone obtainable, it is clear that definite assumptions are scarcely possible. In a great number of cases I came to the conclusion that the only indisputable evidence of low velocity was the lodgment of an undeformed bullet. There is little doubt, moreover, that the general tendency of wounded men was to minimise the range of fire at which they were struck, and again that in the majority of cases in this campaign it was quite impossible to determine whence any particular bullet had come, since the enemy was seldom arranged in one line, but rather in several. Again, smokeless powder was generally employed. Beyond this, in some cases where there was no doubt of the short distance from which the bullet was fired, the wounds were due to 'ricochet' of portions of broken-up bullets. The following instance well illustrates this. A sentry fired five times at two men within a distance of six paces, knocking both down. One man received a severe direct fracture of the ilium, the bullet entering between the anterior superior and inferior iliac spines and emerging at the upper part of the buttock. The entry and exit apertures were large but hardly 'explosive,' as a subcutaneous track four to five inches long separated them. Besides this both men had other lesser injuries; thus in the second two perforating wounds of the arm existed. The latter were not unlike type Lee-Metford wounds, and were regarded as such until a few days afterwards when a hard body was felt in the distal portion of one track and removed. This proved to be a part of the leaden core only, and the similar wound had no doubt been produced by a like fragment, the bullet having broken up on striking the stony ground. _Trajectory._--The comparative flatness of this depends on the construction of the rifle and the propulsive force employed, and varies as does velocity with the nature, excellence, and amount of the explosive, the correctness of the principles upon which the bullet is devised, and the mechanical perfection of its manufacture. Its importance naturally consists in the manner in which it affects the possibility of covering objects on a wide area of ground and thus creating a broad 'dangerous zone.' A bullet fired on level ground from any one of three of the rifles referred to later (Lee-Metford, Mauser, Krag-Jörgensen), sighted to 500 yards and fired from the shoulder in the standing position, will cover some part of an erect man of average height during the whole extent of its flight. A body of men within that distance is therefore in a position of extreme peril in the face of a good shooting enemy. The importance of a flat trajectory is progressively lost, however, with any rifle, as the weapon is gradually sighted to greater distances. Thus when sighted to 2,000 yards the bullet from the Lee-Metford rifle rises 174 feet, and a whole army might comfortably be situated over a considerable area within that distance. The importance of flatness of trajectory is also influenced by the nature of the ground occupied by the combatants. Thus when the area to be covered consists in ground first rising then falling from the rifleman, the trajectory will become more or less parallel to the surface crossed, and the 'dangerous zone' will be correspondingly increased in extent. On the other hand, when the ground slopes away from the rifleman the rise of the projectile is exaggerated, and reaches its most limited capacity of covering an intervening space when the flight crosses a hollow. _Revolution of the bullet._--It only remains in this place to say a few words concerning the revolution imparted to the bullet by the rifling of the barrel. This ensures the flight of the projectile on a line parallel to its long axis, and notably increases its power of penetration. Both these properties of the flight are to the advantage of the wounded, since, as already mentioned, the more exactly the impact corresponds to a right angle with the skin, the more limited will be the area of contusion, even if it be of the most severe character, while to the twist of the bullet must be ascribed a not inconsiderable part in the explanation of the ready and neat perforations of narrow structures which are frequently produced. It has been pointed out that the Lee-Metford bullet turns on its own axis once in a distance of ten inches, while the Mauser revolves once in a distance of eight and eleven-sixteenths inches; hence not more than at most two revolutions are made in tracks crossing the trunk, and not more than half a full revolution in the perforation of a limb. None the less, no one can deny the influence of the one half turn of supination in entering a perforating tool of any description, both as preventing splintering, and in preserving the surrounding parts from damage. Beyond this, the spiral turn of the bullet, by diverting a part of the transmitted vibrations into a second direction, must, in the case of wounds of the body, help to throw off contiguous structures, and while those that are in actual contact are more severely contused, the surrounding ones suffer somewhat less direct injury. It must be borne in mind, also, that rapidity of revolution does not fall _pari passu_ with that of velocity of flight, but that the former undergoes a comparatively slighter diminution until the bullet is actually spent. Hence, the influence of revolution is felt, however low the velocity may be, provided sufficient striking force is retained to enter the body. A word must be added here as to the surface of a discharged bullet; this, in taking the rifling of the barrel, becomes permanently grooved. The depth of the groove differs with the variety of rifle. In the Lee-Metford the grooves are deep (.009), in the Mauser slightly less so (.007), but the surface of both bullets is comparatively roughened when revolving in the body, and this circumstance, since the projectile exactly fits its track, may influence the degree of the surface destruction of tissue, and somewhat aid in the clean perforation of bone, since a little bone dust is always found at the entrance aperture of a canal in cancellous bone. During the campaign many varieties of rifle projecting bullets of widely differing calibre were employed by the Boers, many of whom as sportsmen preferred the rifle to which they were accustomed to a regulation weapon, and an illustration of a large variety of bullets from cartridges which I collected from arsenals and camps is given below (p. 96). The great majority of the men, however, were armed with small-calibre weapons of some sort, and as the wounds produced by these are of chief interest at the present day, I shall say little of any others, beyond an occasional reference to Martini-Henry rifle wounds which may be considered to represent approximately those made by large leaden sporting bullets. [Illustration: FIG. 14.--Type Cartridges in common use during the war. From left to right: Martini-Henry, Guedes, Lee-Metford, (Spanish) Mauser, Krag-Jörgensen] The most important, as the most frequently employed, rifles projecting small-calibre bullets were the Krag-Jörgensen, Mauser, Lee-Metford, and Guedes, given in the order of increase of calibre (from 6.5 to 8 millimetres, or .254-.314 in.) in the bullets. As to the seriousness of wounds produced by these there is little to choose, differences in character being only those of degree. Such differences depended on the area of tissue implicated, corresponding with the calibre of the particular bullet, the comparative weight of the bullet, and the degree of velocity of flight maintained at the moment of impact. When, however, any of these bullets have been exposed in their flight to influences capable of causing deformity of their outline and symmetry, peculiarities of construction and in the composition of the metals employed in their manufacture may materially alter the character of the wounds produced and revolutionise a classification founded purely on the relative weight, calibre, and degree of velocity with which each is endowed. TABLE I [Transcriber's note: table split to fit on page.] +-------------------+----------------+------------------+----------------+ | | Martini-Henry | Guedes | Lee-Metford | +-------------------+----------------+------------------+----------------+ |Calibre of rifle | .45 in. | .314 in. | .303 in. | |Number of grooves | 7 | 4 | 7 | |One twist in | 22 in. to right|9.85 in. to right | 10 in. to left | |Muzzle velocity | 1,300 f.s. | 1,988 f.s. | 2,000 f.s. | |Sighted to | 1,450 yds. | 2,600 paces | 2,800 yds. | |Weight of cartridge| 758 grains |464.05 grains[6] | 416-1/2 grains | |Weight of bullet | 480 grains | 244 grains | 215 grains | |Length of bullet | 1.250 in. | 1.250 in. | 1.250 in. | |Calibre of bullet | .450 in. | .315 in. | .309 in. | |Charge of powder | 85 grains | 20-23 grains | 31-1/2 grains | | | (black powder) | (nitro- | (cordite) | | | | smokeless) | | |Nature of alloy | -- | Mantle: Mild | Cupro-nickel | | used for mantle | | steel, greased | | | of bullet | | | | |Thickness of | -- | -- | Mark II. bullet| | mantle | | | | |Tip | -- | .031 | .036 | |Sides .984 from tip| -- | .011 | .015 | +-------------------+----------------+------------------+----------------+ +-------------------+---------------+--------------------+---------------+ | | Lee-Enfield | Mauser | Krag- | | | | | Jörgensen| +-------------------+---------------+--------------------+---------------+ |Calibre of rifle | .303 in. | .276 in. | .254 in. | |Number of grooves | 5 | 4 | 4 | |One twist in |10 in. to left |8-11/16 in. to right| 8 in. to left | |Muzzle velocity | 2,000 f.s. | 2,262 f.s. | 2,309 f.s. | |Sighted to | 2,800 yds. | 2,187 yds. | 2,406 yds. | |Weight of cartridge| 416-1/2 grains| 384.5 grains | 372.1 grains | |Weight of bullet | 215 grains | 173.3 grains | 156.4 grains | |Length of bullet | 1.250 in. | 1 in. | 1.250 in. | |Calibre of bullet | .309 in. | .280 in. | .260 in. | |Charge of powder | 31-1/2 grains | 38.0 grains | 36 grains | | | (cordite) | (smokeless) |(nitro | | | | | -smokeless) | |Nature of alloy | Cupro-nickel | Mantle: Steel |Mantle: Mild | | used for mantle | | with alloy of | steel coated | | of bullet | | copper on | with copper | | | | surface | nickel, the | | | | | composition of| | | | | the latter | | | | | being that of | | | | | the cupro- | | | | | nickel of the | | | | | Lee-Enfield | | | | | bullet | |Thickness of |Mark II. bullet| -- | -- | | mantle | | | | |Tip | .036 | .031 | .022 | |Sides .984 from tip| .015 | .015 | .015 | +-------------------+---------------+--------------------+---------------+ Some particulars of the four rifles and their projectiles are collated in Table I., to which is added the corresponding information regarding the Martini-Henry for the purposes of comparison. TABLE II.--PENETRATION The penetration of the Martini-Henry and the Lee-Metford or Lee-Enfield rifle with Mark II. bullet is as follows: Martini-Henry 15-1/2 in. of 1 in. deal boards 19 in. of sand 1 in. apart containing 15 per cent. of moisture Lee-Metford {Mark II.} 42 in. of 1 in. deal boards 60 in. of sand Lee-Enfield {bullet } 1 in. apart containing 15 per cent. of moisture The penetration of bullets of .314 calibre differs little from that possessed by the Lee-Metford or Lee-Enfield, of which the muzzle velocities are very little lower, with Mark II. bullet. The Belgian Mauser perforates 55 inches of fir-wood at 12 metres distance. With regard to the penetration of bullets of smaller calibre that of the Roumanian Mannlicher (.256) may be taken as typical. When fired into a sand butt at 25 yards the bullet enters 9 inches and then breaks up. The comparative size of the different cartridges is shown in fig. 14. The general remarks already made as to the effect of weight, calibre, and velocity sufficiently explain the importance of the particulars given in this table, but it will be noted that the Lee-Metford rifle is inferior to both the Krag-Jörgensen and Mauser rifles in the initial velocity transmitted to its bullet. The tendency to equalisation, in this particular, when the remaining velocity is considered, has been mentioned; but it may be of interest if I quote from Nimier and Laval[7] the scale on which the decrease in velocity takes place in the case of the three weapons. METRES PER SECOND +---------------------+-------------+--------+----------------+ | | Lee-Metford | Mauser | Krag-Jörgensen | +---------------------+-------------+--------+----------------+ | | | | | | Initial velocity | 630 | 718 | 720 | | Remaining velocity: | | | | | At 100 metres | 574 | 699 | 718 | | At 1,000 metres | 249 | 264 | 269 | | At 2,000 metres | 159 | 165 | 165.9 | | | | | | +---------------------+-------------+--------+----------------+ Giving full importance to the effects of velocity as a factor in the severity of the injuries produced, when the large proportion of wounds received at distances above 1,000 yards is borne in mind, we see how rapidly the superiority of the smaller projectiles is lost. This loss, even in the early stages, is probably more than made up for in the case of the Lee-Metford, when the superiority in weight, calibre, and bluntness of extremity as contributing to striking force is taken into consideration. The striking force (kinetic energy) of a bullet is indicated by the following formula: F = 1/2 mv.^{2}; that is to say, the striking force is equal to half the weight of the bullet multiplied by the square of the velocity. In point of fact, with unaltered regulation bullets I was never able to determine any very material difference between the wounds produced, further than that the wounds of entry and exit in the soft parts tended to correspond with the calibre of the particular bullet concerned. Although the immense majority of the wounds which came under my notice were caused by the Mauser bullet, yet I saw some hundreds of wounded Boers and a good many of our own men wounded by Lee-Metford bullets, in the latter case no doubt by some of the sporting varieties. The only cases that I can call to mind or have noted as exhibiting a superior wounding power in the Lee-Metford bullet are some injuries to bone. Thus I saw a considerable number of clean perforations of the patella produced by Mauser bullets, while the only two Boers whom I saw with injured patellæ had suffered transverse fractures. Again, I have a lively recollection of an old Boer who had suffered a fracture of the middle third of the femur, in the thigh of whom, with small apertures of entry and exit, a cavity of destroyed tissue, five inches across, was found beneath the fascia lata at the distal side of the fracture. I cannot however say that I did not observe many equally severe injuries to the femur produced by Mauser bullets in our own men, and as far as fractures of the skull went, a somewhat crucial test, among the men brought off the battlefield alive, I never saw any difference in severity whatever. [Illustration: FIG. 15.--Sections of four Bullets to show relative shape and thickness of mantles. From left to right: 1. Guedes; regular dome-shaped tip; mild steel mantle; thickness at tip 0.8 mm.; at sides of body 0.3 mm. 2. Lee-Metford; ogival tip; cupro-nickel mantle; thickness at tip 0.8 mm.; gradual decrease at sides to 0.4 mm. 3. Mauser; pointed dome tip, steel mantle plated with copper alloy; thickness at tip 0.8 mm.; gradual decrease at sides to 0.4 mm. 4. Krag-Jörgensen; ogival tip as in Lee-Metford; steel mantle plated with cupro-nickel; thickness at tip 0.6 mm.; gradual decrease at sides to 0.4 mm. The measurements of the sides are taken 2.5 cm. from the tip. Note the more gradual thinning in the Lee-Metford mantle.] These points of comparison having been made, it only remains to consider one other point, that of the relative stability of the bullets. This is a matter of the greatest importance as regards the regularity or otherwise of the wounding power of the projectile, and, as far as my experience went, I believe the Mauser to far exceed the Lee-Metford in instability of structure. The core of all four bullets is composed of lead hardened by a certain admixture of tin or antimony, but the mantle differs in composition, thickness both general and in different parts of the bullet, mode of fixation, and consequently in its power of resistance to violence. Fig. 15 gives an exact representation of the relative thickness of the mantles, and shows the general tendency to a thickening of the mantle at its upper extremity, designed to increase both the stability and striking power of the projectile. It will be noted that in general stoutness the Lee-Metford stands first, as the case increases gradually in thickness from base to apex. Beyond this it must be noted that the Lee-Metford is the only one of the four that is ensheathed with a mantle composed of a definite alloy, this consisting of 80 parts of nickel and 20 of copper. Two of the remaining bullets, the Mauser and Krag-Jörgensen, are ensheathed with steel covered with a thin coating of an alloy of copper or cupro-nickel, to take the rifling of the barrel, while the third has a plain steel mantle which is covered with a layer of wax to take the place of the nickel used in the manufacture of the two others. It is interesting to mention here that the Boers evidently found the copper alloy coating insufficient for its purpose, or at any rate not satisfactory in preserving the weapon from the ill-effects consequent on the friction between the steel case and the rifling of the barrel, as at about the middle of the campaign they began to use their bullets waxed, as in the case of the Austrian Mannlicher; hence the legend of the poisoned bullets which caused such a sensation for a short period amongst the uninitiated. It is possible also that the additional layer of wax was necessitated by the wearing of the barrel. The wax employed for the Mauser bullets was not originally green. Mr. Leslie B. Taylor informs me that it is probably paraffin wax, the green colour depending on the formation of verdigris from the copper alloy with which the steel envelopes are plated. This completely corresponds with my own experience, since on the bullets in my possession the green colour, originally pale, has steadily increased in depth. Many old leaden bullets I found in the Boer arsenals were also waxed, but in this case no alteration in colour had taken place. The Guedes bullets, which are cased in mild steel, become somewhat brown with exposure from a similar oxidation or rusting of the surface. As far as my experience went, however, the steel casing has an important surgical bearing beyond the mere question of wear and tear on the rifle barrel. That it possesses elasticity and capability of bending is obvious, and in a later chapter, devoted to irregular wounds, several illustrations of such deformities are given; but when it strikes stone I believe it splits and tears with very much greater freedom than the cupro-nickel mantle of the Lee-Metford. At any rate, I never came across Lee-Metford bullets deformed to the same degree as Mauser bullets, either when removed from the body, or as ricochet projectiles on the field of battle. For this reason, therefore, provided the fighting takes place on stony ground, I believe the Mauser bullet and others ensheathed in steel to be much more dangerous surgically than those encased in cupro-nickel. I fancy this would be equally the case even if the mantles were of exactly the same thickness. The layer of copper alloy on the steel mantles is also a physical characteristic worthy of mention. This very readily chips off in a manner similar to that we are accustomed to see with nickel-plated instruments. This may be due to the compression into the grooving of the rifle, or as the result of passing impact of the bullet with an obstacle previous to entering the body or contact with a bone within it. Small scales of metal set free in one of these ways are seen in a very large proportion of Mauser wounds, and although they are so small as usually to be of little importance, the presence of such in, for instance, the substance of one of the peripheral nerves which has been perforated cannot be considered a desirable complication. To recapitulate, it would appear that at mean ranges, both in striking force and as regards the area of the tissues affected, the Lee-Metford is a superior projectile to the Mauser, in spite of the greater initial velocity possessed by the latter. On the other hand the comparative ease with which the Mauser bullet undergoes deformation either without or within the body, so ensuring more extensive injury and laceration, renders it the less desirable bullet to receive a wound from when not in its normal shape and condition. I can say little about the remaining two rifles. The Krag-Jörgensen was little used, and beyond pointing out its capacity to inflict very neat individual injuries, in which it must surpass even the Mauser, I can only add that I had no opportunity of forming an opinion as to the danger dependent on the great initial velocity imparted to the bullet. The Guedes rifle has been included in the table because it approximates in bore to the other three. Its bullet is of the same calibre as the Austrian Mannlicher, one of the most powerful military rifles in use, and it was used to a considerable extent during the war by the Boers.[8] As to its capabilities, it appeared an inferior weapon, since want of velocity and striking power of the bullets was indicated by the number of these which were retained in the body, and by the fact that I never saw one extracted that had undergone any more serious deformation than some flattening on one side of the tip. On the other hand wounds of the soft parts occasioned by it were only to be distinguished from Mauser wounds by their slightly greater size, and at a short range of fire the weight and volume of the bullet made it a dangerous projectile. The question of deformed bullets will be again referred to at length in the section on wounds of irregular type, and a number of type specimens are there figured and described (p. 76). In the same chapter will be found illustrations of a number of sporting bullets of small calibre, as well as of large calibres in lead, found in the Boer arsenals and camps. I have placed them in that position as mainly of interest in connection with the occurrence of large and irregular wounds (see figs. 42 and 43, pp. 95 and 98). The small sporting bullets were mostly of the Mauser (.276), Lee-Metford (.303), or Mannlicher (.315) calibre. FOOTNOTES: [5] See tables, pp. 12, 13, 15, Chapter I. [6] The weights are from cartridges brought home. The charge of powder was small and variable. [7] H. Nimier and E. Laval, _Les Projectiles des Armes de Guerre_, p. 20. F. Alcan. 1899. [8] Mr. Leslie B. Taylor informs me that this rifle is a discarded Portuguese regulation pattern, with which a copper-ensheathed soft-nosed bullet was originally employed. For the purposes of the present campaign a modified cartridge was constructed. Examination of some specimens in my possession showed the charge of powder to be very small. (Table I. p. 48.) CHAPTER III GENERAL CHARACTERS OF WOUNDS PRODUCED BY BULLETS OF SMALL CALIBRE The effects of injuries inflicted by bullets of small calibre may be divided into two classes: 1. Direct or immediate destruction of tissue. 2. Remote changes induced by the transmission of vibratory force from the passing projectile to neighbouring tissues or organs. Those of the first class will be mainly considered in this chapter; the remote effects will be dealt with under the headings devoted to special regions. In dealing with the wounds as a whole I shall first describe those of uncomplicated character as type injuries, and deal with those possessing special or irregular characters separately. TYPE WOUNDS 1. _Nature of the external apertures._--The apertures of entry and exit in uncomplicated cases are very insignificant, but the size naturally varies slightly with that of the special form of bullet concerned. As will be shown moreover, the difference in size is the only real distinguishing characteristic in many cases between wounds produced by the modern bullet of small calibre and those resulting from the use of the older and larger projectiles of conical form. I have been very much struck on looking over my diagrams of entry, and especially exit, wounds to find that they reproduce in miniature most of those figured in the History of the War of the Rebellion; some of these diagrams are reproduced in this chapter. _Aperture of entry._--The typical wound of entry with a normal undeformed bullet varies in appearance according to whether the projectile has impinged at a right angle or at increasing degrees of obliquity, or again, to whether the skin is supported by soft tissues alone, or on those of a more resistent nature such as bone or cartilage. [Illustration: FIG. 16.--Mauser Entry and Exit Wounds. A, entry in buttock; circular opening filled with clot and crossed by a tag of tissue. B, exit in epigastrium near mid-line; irregular slit form, with well-marked prominence. Specimens hardened in formalin immediately after death; the resulting contraction has slightly exaggerated the irregularity of outline of the entry wound] [Illustration: FIG. 17.--Gutter Wound of outer aspect of shoulder, caused by a normal Mauser, which subsequently perforated a man's leg. At the central part the gutter was 3/4 in. deep a few days after the injury] When the bullet impinges at a right angle the wound is circular, with more or less depressed margins, and of a diameter, corresponding to the size of the bullet occasioning it, from a quarter to a third of an inch. The description 'punched out' has been sometimes applied to it, but it would be more correct to reverse the term to 'punched in,' since the appearance is really most nearly simulated by a hole resulting from the driving of a solid punch into a soft structure enveloped in a denser covering. The loss of substance, moreover, in the primary stage is not actually so great as appears to be the case, fragments of contused tissue from the margin being turned into the opening of the wound track. The true margin therefore is not sharp cut, and the nature of the line differs somewhat according to the structure of the skin in the locality impinged upon. Thus the granular scalp and the comparatively homogeneous skin of the anterior abdominal wall will furnish good examples of the nature of the slight difference in appearance. From the first the margin is also often somewhat discoloured by a metallic stain, similar to that seen when a bullet is fired through a paper book. This ring is, however, narrow, and not likely to be noticeable when the bullet has passed through the clothing. In any case it is subsequently obscured by the development of a narrow ring of discoloration due to the contusion. This latter varies in width, and still later a halo of ecchymosis half an inch or more in diameter surrounds the original wound. [Illustration: FIG. 18.--Oblique Exit Gutter. Diagram enlarged to actual size from case shown in fig. 24, p. 64.] With increasing degrees of obliquity of impact more and more pronounced oval openings of entry result, culminating in an actual gutter such as is seen in fig. 17. In all oval openings the loss of substance is more pronounced at the proximal margin, while the wound is liable to undergo secondary enlargement at the distal margin, since in the former the epidermis is mainly affected, while in the latter the epidermis is spared as an ill-nourished bridge, the deeper layers of the skin suffering the more severely. When the wound occurs in regions, such as the chest-wall or over the sacrum, where the skin is firmly supported, the oval openings are often very considerable in size, reaching a diameter at least double that of the circular ones. In the case of the oval openings the depression of the margins is not such a well-marked feature as in wounds resulting from rectangular impact of the bullet, since the distal margin is really lifted. [Illustration: FIG. 19.--Oval Entry Wound over third sacral vertebra. Exit wound, anterior abdominal wall. Slightly starred variety. Diagram made on second day] _Aperture of exit._--The wound of exit in normal cases offers far more variation in appearance than that of entry, this variation depending on several circumstances: first, the want of support to the skin from without, and such other factors as the degree of velocity retained by the travelling bullet, the locality of the opening, and the density, tension, and resistance offered by the particular area of skin implicated. When the range has been short and the velocity high, it is often difficult to discriminate between the two apertures. Both may be circular and of approximately the same size, and the only distinguishing characteristic, the slight depression of the margin of the wound of entrance, may be absent if any time has elapsed between the infliction of the injury and examination by the surgeon. One very strong characteristic if present is the general tendency of the margins, and even the area surrounding the exit wound itself, to be somewhat prominent. Fig. 16 shows this point, although the wound from which it was drawn had been produced thirty-six hours before death. The specimen was then hardened in formalin and still preserves its original aspect. This character is, however, more frequently displayed in wounds received at mean, or longer, ranges. In wounds produced by bullets travelling at the highest degrees of velocity it is often absent. [Illustration: FIG. 20.--Circular Entry back of arm; exit (bird-like) in anterior elbow crease] [Illustration: FIG. 21.--Circular Entry over patella. Starred exit of elongated form in popliteal crease] When the range of fire has been greater and the velocity retained by the bullet lower, slit wounds are common, or some of the slighter degrees of starring. Actual starring I never saw, but reference to figs. 20 and 21 will show a tendency in this direction, also a close resemblance to the starred wounds resulting from perforations by large leaden bullets. Such wounds, I believe, are usually the result of a somewhat low degree of velocity. Slit exit wounds may be vertical or transverse (fig. 20) in direction, and the production of these is dependent on the locality in which they are situated, the thickness, density, and tension of the skin, and the nature of the connection of the latter with the subcutaneous fascia in the locality. Thus in wounds of different parts of the hairy scalp, so little variation exists in the relative density and structure of the skin, that, in spite of the want of external support at the aperture of exit, it is often difficult to discriminate offhand the two apertures, if neither bone nor brain débris occupies that of exit. If, however, a wound crosses from side to side a region such as the thigh where well-marked differences exist in the subjacent support, thickness, and elasticity of the skin implicated in the apertures, the wound of entry, if in the thick skin of the outer aspect, was usually circular, while the exit in the thin elastic skin of the inner aspect was either slit-like or starred. The difficulty in laying down any general rule as to the occurrence of circular or slit apertures of exit in any definite region is, however, great, as may be seen by reference to the accompanying diagrams taken from two patients wounded at Paardeberg (figs. 22 and 23). In fig. 22 the bullet entered the outer and posterior aspect of the left buttock, crossed the limb behind the femur, and emerged at the inner aspect by a vertical slit: the bullet then entered the scrotum by a vertical slit, and emerged by a typical circular aperture; re-entered the right thigh by a transverse slit aperture, and, striking the femur in its further course, underwent deformation, and finally escaped by an irregular aperture 3/4 of an inch in diameter. The occurrence of exit slits in the adductor region is common, and to be explained by the tendency of the comparatively thin elastic skin to be carried before the bullet; the slit entry in this position must, I suppose, be explained by the comparatively slight support afforded by the underlying structures, which are often in a condition of hollow tension. The scrotal wounds are perhaps more difficult to account for, but in this case the fact of the distal aperture being directly supported by the right thigh is a ready explanation of the circular exit, while the skin corresponding to the slit entry was no doubt carried before the bullet, and finally gave way in the line of a normal crease. [Illustration: FIG. 22.--Entry and Exit Wounds in both thighs and scrotum. From right to left: 1. Circular entry in left buttock behind trochanter. 2. Vertical slit exit in adductor region. 3. Slit entry in scrotum (probably inverted before bullet broke the surface, and then a slit occurred in a normal crease). 4. Circular exit in scrotum (here supported by surface of right thigh). 5. Transverse slit entry in right adductor region. 6. Irregular 'explosive' exit, the bullet having set up on contact with the front surface of the femur, but without having caused solution of continuity of the bone.] In fig. 23 all the wounds are circular except the final exit, which was irregular as a result of the bullet in this case also having struck the femur in the second thigh. Considerable variation also exists in the size of the circular apertures; this illustrates the secondary enlargement often occurring in such wounds, and most marked at the apertures of entry, as the more contused. Both diagrams were made from patients eight days after the reception of the wounds. [Illustration: FIG. 23.--Wound of both Thighs. First and second entry typical circular wounds. First exit a small circular wound; the bullet 'set up' on contact with the femur without causing solution of continuity of the bone, and second exit is irregular and large. This diagram is of considerable interest when compared with fig. 22. I believe the comparative regularity in the wounds to have been due to a higher degree of velocity of flight on the part of the bullet] Lastly, vertical or transverse slits may be looked for with considerable confidence in situations in which transverse oblique or vertical folds or creases normally exist in the skin, and depend on the lines of tension maintained by the connection of the skin in these situations to the underlying fascia. Thus I saw well-marked transverse and vertical slits in the forehead corresponding with the creases normally found there, and in this situation I noted some slit entries. Transverse slits were common in the folds of the neck, the flexures of the joints (fig. 20), and the anterior abdominal wall either in the mid line or in creases like those stretching across from the anterior superior iliac spines. Again they were seen in the palms and soles, but here more readily tended to assume the stellate forms. Vertical slits are less common; they occurred with the greatest frequency in the posterior axillary folds. Oval apertures of exit are far less common than those of entry, since the most common factor for the production of an oval opening, bony support, is never present. In long subcutaneous tracks, or very superficial wounds, they are however sometimes met with and may terminate in a pointed gutter (see figs. 18 and 24). The greatest modifications in the appearance and nature of the apertures of entry are dependent on previous deformation of the bullet, when all special characteristics are lost, and it becomes impossible to form any opinion as to the type of bullet concerned. These modifications are naturally far more common in the aperture of exit, since the bullet so often acquires deformity in the body as the result of impact with the bones. Further remarks on this subject will be found with the description and comparison of the various bullets on p. 81. [Illustration: FIG. 24. Superficial Thoracico-abdominal Track. Small entry: discoloration of surface over costal margin from deep injury to skin; well-marked 'flame' gutter exit (see fig. 18)] 2. _Direct course taken by the wound track._--This character primarily depends on the velocity with which bullets of small calibre are made to travel, and on the small area of the tissues upon which they operate. In this relation the degree of velocity retained by the bullet is often of minor importance, provided it be sufficient to penetrate the body. Fired within a distance of 2,500 yards there is little doubt that a bullet of the Lee-Metford, Mauser, or Krag-Jörgensen types, passes straight between the apertures of entry and exit when these are of the type outline, even when the bones are implicated. By reason of the small size of the projectiles, their shape, and the spin and velocity transmitted to them, there is no reason why at a sufficiently short range they should not traverse the body from the crown of the head to the sole of the foot. The necessary conditions of position and distance for such an injury are obviously not often obtained, but it may be pointed out that the Belgian Mauser rifle at a distance of five yards is capable of driving a bullet 55 inches or nearly five feet into a log of pine-wood. Many examples of long tracks will be referred to later, but the following instances may be of interest in this relation. A bullet entering at the occipital protuberance traversed the muscles of the neck, passed through the thoracic cavity, fractured the bodies of the third and fourth and grooved the seventh and eighth dorsal vertebræ, grooved the seventh and eighth and fractured the ninth and tenth ribs, traversed the muscles of the back and finally lodged against the ilium; the whole length of this track measured some 25 inches. Again, at the battle of Belmont a Mauser bullet entered the pelvis of a horse just below the anus, and traversed the entire trunk before emerging from the front of the chest: it may be of interest to mention that this animal was alive and moving about the next day, but I am sorry I can give no further information regarding his fate. [Illustration: FIG. 25.--Superficial Track on external surface of Thigh. Local discoloration of skin five weeks after reception of injury] The possibility of contour tracks travelling around the walls of the chest or abdomen has therefore rarely to be considered, except in occasional instances where the bullet fired from a long range has impinged against a bone and is retained in the body. The small volume of the bullets, however, allows the production of very prolonged direct subcutaneous tracks in the body wall, in positions where they would be manifestly impossible with projectiles of larger calibre. Figs. 24 and 25 illustrate wounds of this nature. In the case figured in fig. 24 the bullet entered over the third rib in a vertical line above the right nipple; it then coursed obliquely down, crossing the seventh costal cartilage, and finally emerged 3 inches above the umbilicus. Where the track crossed the prominence of the thoracic margin the skin was so thinned as to undergo subsequent discoloration, while a distinct groove was evident there on palpation. In some similar cases I have seen the central part of the track secondarily laid open as a result of the thinning of the skin and consequent sloughing due to the interference with its vitality. Short of sloughing, the skin may show signs of alteration of vitality for a long period after the injury; thus fig. 25 depicts the condition seen in a superficial wound of the thigh five weeks after the injury. The line of passage of the bullet between the two openings was still clearly visible as a dark red coloured streak. Grooves in such cases are generally readily palpable in the early stages, while later the want of resistance is replaced by the readily felt firm cord representing the cicatrix. These points are of much importance in discriminating between perforating and non-perforating wounds of the abdomen, and are again referred to in that connection. The direction of the tracks obviously depends on the attitude assumed by the patient at the moment of impact of the bullet and the direction whence the firing has proceeded. The frequent assumption of the prone position during the campaign led to the occurrence of a large proportion of longitudinal tracks in the trunk, or trunk and head, which will be referred to later. Certain battles were in fact strongly characterised by the nature of the wounds sustained by the men. Thus at Belmont and Graspan, where some rapid advances were made in the erect attitude, fractured thighs were proportionately numerous, while at Modder River, where many of the men lay for a great part of the day in the prone position, glancing wounds of the uplifted head, of the occipital region, or longitudinal tracks in the trunk and limbs were particularly frequent. I very much regret that the material at my disposal does not allow me to add some remarks as to variation in the nature of the wounds according to whether they were received from an enemy firing from a height or from below, but it is possible that some information on this subject may be forthcoming when the returns of the Service are made up, since it is naturally of great importance as to the effect of trajectory in the proportionate occurrence of hits. 3. _Multiple character of the wounds._--The same conditions responsible for the length and directness of the tracks, account for the frequently multiple character of the wounds implicating either the limbs or viscera--thus, lung, stomach, liver; neck, thorax, abdomen; abdomen, pelvis, thigh. Also for the frequent infliction of two or more separate tracks by the same bullet--thus, arm and forearm with the elbow in the flexed position; both lower extremities; both lower extremities, penis or scrotum; leg, thigh, and abdomen, with a flexed knee; upper extremity and trunk, and more rarely one upper and one lower extremity. Again, it was remarkable how often the same bullet would inflict injuries on two or more separate men, not unfrequently dealing lightly with the first and inflicting a fatal injury on the second, or vice versâ. The small calibre of the bullet, moreover, allows of the neatest and most exact multiple injuries. Thus in a patient who was crawling up a kopje on all fours, the flexed middle digit of the hand was struck. The bullet entered at the base of the nail, first emerged at the distal interphalangeal flexor fold, re-entered the metacarpo-phalangeal fold, and finally emerged from the back of the hand between the third and fourth metacarpal bones. 4. _Small 'bore' of the tracks, and tendency of the injury to be localised to individual structures of importance._--Here we meet with the most striking characteristic of the injuries, and evidence that reduction of calibre affects more strongly the nature of the lesion than does any other element in the structure of the modern rifle. The diameter of the track slightly exceeds that of the external apertures, probably as a result of the more ready separability of the elements of the structures perforated than exists in the skin. The calibre, moreover, tends to be fairly even throughout when soft structures only are implicated, though local enlargements result wherever increased resistance is met with. Thus a strong fascia may offer such resistance as to increase locally the bore of the track, and in this particular the state of tension of the fascia when struck will affect the degree of the enlargement. The most striking instances of local enlargement of the track are of course seen when a bone lies in the course of the bullet, but we must here bear in mind the introduction of a new element--the propulsion of comminuted fragments together with the bullet itself. In cases of fracture the distal portion of the track is in consequence many times larger than the proximal. The most striking examples of small even tracks are seen, on the other hand, in punctures of the elastic and practically homogeneous lung tissue, where the wounds are extremely small. On transverse section of the track the gross amount of actual tissue destruction occupies a lesser area than that corresponding to the diameter of the bullet. The destructive action of the projectile is in fact exerted mainly on the tissues directly lying in its course, the track being opened up during the rush of the passage of the bullet, partly as a result of its wedge-like shape and partly as a result of the throwing off of the tissues forming the walls of the track by a diversion of a portion of the force in the form of spiral vibrations dependent on the revolution of the bullet. Again, the opening out of the tissues may be aided by the direction taken by the first and strongest as well as the simplest series of vibrations transmitted, which would assume the shape of a cone of which the point of impact forms the apex. The escape from actual destruction by structures lying in the immediate neighbourhood of the track is indeed often surprising, but not perhaps so astonishing as the perforation of long narrow structures such as the peripheral nerves and vessels, without irreparable damage to the parts remaining, and this although the structures themselves may be of a diameter not exceeding that of the bullet itself. The capacity of these projectiles to split such structures as tendons was already well known before our experience in this campaign, but the injuries to the nerves and vessels of the same character came as a surprise to most of us. The lateral displacement of tissues seems to bear a strong resemblance to what is seen on the passage of an express train, when solid bodies of considerable weight are displaced by the draught created without ever coming into contact with the train itself. The tendency to lateral displacement is still more strongly exhibited when dense hard structures such as bone are implicated. Here the fragments at the actual points of impact on the proximal and distal surfaces of a shaft are driven forwards, while the lateral walls of the track in the bone are simply comminuted and pushed on one side without loss of continuity with their covering periosteum. The extension of this form of displacement to a degree amounting to a so-called explosive character in the case of the soft tissues, even when the bullet passed at the highest degrees of velocity, was, however, never witnessed by me, and I very much doubt the existence of a so-called 'explosive zone' so far as wounds of the soft parts are concerned. On the contrary, I am inclined to believe that the highest degrees of velocity are favourable to clean-cut neat injuries of the soft tissues. I saw a large number of type wounds of entry and exit inflicted at a range of under fifty yards. 5. _Clinical course of the wounds._--The tendency of simple wounds such as are above described to run an aseptic course was very marked, and, given satisfactory conditions, deep suppuration and cellulitis were distinctly rare. It may also be confidently affirmed that when suppuration did occur, with apertures of entry and exit of the normal small type, this was always the result of infection from the skin, or infection subsequent to the actual infliction of the wound. The infrequency of suppuration depended on the aseptic nature of the injury, the smallness of the openings, the small tendency of the track to weep and furnish serous discharge in any abundance, the comparative rarity of the inclusion of fragments of clothing or other foreign bodies, and possibly in some degree on the purity and dryness of the atmosphere, which favoured a firm dry clotting of the blood in the apertures of entry and exit, and consequent safe 'sealing of the wound.' As to the aseptic nature of the injury, it will be well to first consider the question of the sterility of the bullet. Putting laboratory experiments on one side, the large experience of this campaign seems to prove to absolute demonstration that, bearing in mind the very large proportion of instances of primary union in simple tracks, the surgeon has nothing to fear on the part of the bullet itself. This is the more striking when we remember that these bullets shortly before their employment were carried in a dirty bandolier, and freely handled by men whose opportunities of rendering either their hands or implements aseptic were as bad as it is possible to conceive. Several explanations are to hand, but none of them conclusive. Two must, however, be shortly considered. First, the surface of the bullet, except its tip and base, is practically renewed by passage through the barrel. Secondly, there is the question of the heat to which it is subjected. As far as cauterisation of the tissues is concerned, this question has been practically settled in the negative, since actual determinations of the heat immediately after the moment of impact have been made, and again it has been shown that butter is not melted, and that neither gunpowder nor dynamite is exploded, by firing bullets through small quantities of those materials. Again, the absence of any sign of scorching of the clothes of the wounded is strong evidence against the possibility of any considerable heat being applied to the tissues of the body; while another observation, although of less importance as affecting spent bullets only, that bullets, which have perforated the body but lie between the skin and the clothing, leave no sign of cauterising action on either, may be mentioned. None the less, the sources of heating while the bullet is passing from the barrel are many and obvious. Thus there is the heat consequent on explosion of the powder, the warm state of the barrel itself when the rifle has been fired a few times consecutively, and the heat resulting from the force and friction essential to the propulsion of the bullet through the barrel. Again, bullets covered with wax before their introduction into the barrel retain no trace of this when they have been fired, although at any rate the portion covering the tip is not exposed to friction on the part of the rifle, and lastly the base of the bullet has no other explicable reason for its innocuousness than subjection to a certain degree of heat. While not claiming any cauterising action on the tissues by the bullet, I should therefore still be inclined to allow the probability of the heat to which the surface of the bullet is exposed exerting a cleansing action on the projectile. In regard to this point it is interesting to bear in mind that shots from an ordinary gun seldom or never give rise to infection. Foreign bodies were rarely carried into the wounds with the bullet. I saw several instances in which portions of the metal of cigarette cases and of cartridge cases when the bullet had perforated cartridges in the wounded man's bandolier, and in one instance small pieces of glass from a pocket mirror, must have been carried in without any obvious ill effect. Fragments of clothing, on the other hand, in every case caused suppuration: clothing was not often carried in, the khaki linen was perforated with a clean aperture, most commonly a slit; but the thick woollen kilts of the Highlanders, and thick flannel shirts, occasionally furnished fragments. The introduction of large pieces of clothing is a sure proof of irregularity of impact on the part of the bullet. The frequency with which portions of cloth were introduced from the kilt was one of the strongest surgical objections to its retention as a part of the uniform on active service. Retained bullets themselves remained as foreign bodies in a certain number of cases. I cannot say that suppuration never followed the retention of a bullet, since in two of the instances where I saw such removed they lay in a small cavity containing at any rate a 'purulent fluid.' In one of these the bullet was a Martini-Henry, and in both the bullet had been imbedded for some weeks, and had certainly not occasioned a primary suppuration of the wound. The favourable influence of the pure and dry nature of the atmosphere in this campaign must certainly not be underrated, and in support of this influence I think I may say, from the experience of cases that I saw coming from Natal where the climate and surroundings were not so favourable as on the western side, that suppuration was more common and more severe in the moister atmosphere. Putting aside all the above remarks, however, I am inclined to think that a general tendency to primary union and the absence of suppuration will always be a feature of wounds from bullets of small calibre, and that this favourable tendency is attributable to certain inherent characters of the injuries. Of these the nature and small size of the openings, the dry character of the lining of the track due to superficial destruction and condensation of the tissue forming its wall, the small disposition to prolonged primary hæmorrhage, and the absence of any great amount of serous exudation during the early stages of healing are the most important. A mechanical factor of great importance also exists in the spontaneous collapse and automatic apposition of the walls of the track. This closure is rendered additionally effective in many cases by the interruption of the continuous line in the wounded tissues consequent on alteration in the position of the parts traversed when an attitude of rest is assumed by the injured part. The indisposition to suppuration and the apparent unsuitability of the tissue lining the track for the development and spread of infecting organisms are well illustrated by several observations. Thus, even if the bullet be thoroughly aseptic, the fragments of destroyed skin driven into the track by the bullet can scarcely be free from organisms; yet these seldom give rise to trouble. Again, if for any reason a deep portion of a track becomes infected and suppurates, there is no tendency for the spread of infection along the line of wounded tissue, but rather for the development of a local abscess, pointing in the ordinary direction of least resistance, irrespective of the course originally taken by the bullet. [Illustration: PLATE I. Engraved and Printed by Bale and Danielsson, Ltd. G. L. CHEATLE. Mauser Wound of Entrance, a little more than 48 hours after infliction. About 12/1. Section of the entry segment of an aseptic Mauser wound removed a little over forty-eight hours after its infliction. Magnified twelve diameters. The margins of the opening are still sloping and depressed, indicating the originally 'punched-in' nature of the aperture. A thin stratified layer of epidermis completely closes it. No scab remains. The wound track is occluded by an effusion of lymph, commencing organisation of which is shown under a higher magnifying power by the presence of leucocytes near the margin of the bounding tissue, and some giant cells. The effusion of lymph occupies a slightly wider area immediately beneath the papillary layer of the skin, then narrows, and broadens again as the subcutaneous fascia is reached, indicating the effect of resistance in widening the area of damage. The subcutaneous connective tissue bounding the track shows little sign of alteration beyond a general slight tendency of the lines of structure to deviate in the direction of the passage of the bullet. No hæmorrhage is apparent beyond a small collection of blood situated immediately beneath the new layer of epidermis at the left-hand corner of the opening. Range probably within 800 yards. Seat of wound, abdominal wall a highest point of iliac crest.] Fig. 25 (_a_), A (plate I.) represents a section carried across an aseptic aperture of entry. The specimen was removed by Mr. Cheatle from a patient who died forty-eight hours after reception of the injury. It shows well the small amount of gross destruction suffered by the subcutaneous tissue, and the rapid repair which follows, since macroscopically the track is scarcely discernible. Reference to plate I. shows the remarkable fact that even at this early date considerable progress towards definite healing has occurred, and a thin layer of stratified epidermis covers the original opening. The question may be raised whether the origin of this epidermal layer is not in part a floating up of the margins of the main aperture. During the course of healing some variation takes place in the appearance of the apertures, especially that of entry. This, at first contracted, later becomes somewhat relaxed, while in many cases a small halo of ecchymosis develops around it. The blood-clot occupying its centre now contracts, the margins rapidly become approximated centripetally, and a small circular dark spot only remains, which is later replaced by a small red cicatrix. The dark central spot under these circumstances consists of the contused margin of the wound in the skin, and a small proportion of blood-clot which finally comes away as a small dry scab. When slight local infection occurs in place of simple contraction and dry scabbing, the process is prolonged, the contused margin separates by granulation, the clot in the opening breaks down, and a small ulcer of somewhat larger proportions than the original wound remains and takes some days to heal. [Illustration: FIG. 25 (_a_).--_A._ Wound of entry 48 hours after reception. _B._ Wound of exit, 7-1/2 days after reception. 1. Skin. 2. Subcutaneous fat carried into the lips of the wound by the bullet. 3. Infected blood extravasation in subcutaneous tissue. Exact size. (See plates I. and II.)] The aperture of exit in simple wounds of the soft parts sometimes heals even more rapidly than that of entry, and if of the slit form may be almost invisible at the end of ten days or a fortnight, actual primary union having taken place as after a simple small incision. Larger or irregular exit apertures, however, take a longer period to close than entry wounds, and this is most often observed when the bullet has undergone deformation within the body, or bone fragments have been driven out with the bullet. Fig. 25 (_a_), B (plate II.) represents a section of an infected exit aperture from a patient who died seven and a half days after its infliction. Two main points of interest are at once apparent: 1. The carrying forwards of the subcutaneous fat into the lips of the skin wound by the bullet. This illustrates the manner in which lightly supported structures are carried forward by the bullet, and throws some light on the mode by which vessels and nerves may escape by a process of displacement. This figure may be compared with fig. 25 (_b_) which shows a tag of omentum similarly carried forward by a bullet crossing the abdominal cavity and plugging the exit wound. 2. The second feature of interest is the amount of hæmorrhage into the subcutaneous tissue. In this respect the contrast between the exit and entry apertures is marked, since in the latter hæmorrhage is scarcely apparent. The presence of such hæmorrhages is explained by the same dragging action as the extrusion of the fat, and is of course dependent on consequent rupture of small vessels. It is of importance as predisposing the exit wound to more easy infection, and it accounts for the persisting subcutaneous induration more often detected beneath healed exit than entry apertures. Again, it suggests that the presence of blood in the deeper parts of the tracks may be the determining cause of the indurated cords often replacing them. [Illustration: PLATE II. Engraved and Printed by Bale and Danielsson, Ltd. G. L. CHEATLE. Mauser Wound of Exit, 7-1/2 days after infliction. Healing delayed by Infection. About 12/1. Section of the exit segment of a Mauser wound, removed seven and a half days after infliction. Magnified twelve diameters. The healing process has been delayed by infection. There is no attempt at closure by a layer of epidermis, and the margins are not depressed. The wound track is narrower than that seen in the entry wound plate I., and completely occluded by a plug of the subcutaneous fat which has been carried forward by the bullet in its passage. A small wedge-shaped plug of lymph indicates the position of the actual track at its termination. Dragging on the surrounding tissue consequent on the extrusion of the plug of fat has ruptured some capillaries, and given rise to considerable extravasation of blood, which is seen as a darker layer in the deepest portion of the wound. Comparison of this plate with the exit wound depicted in fig. 16, p. 56, explains the nature of the tags of tissue there seen to protrude from the convex opening. Range 800 yards. Seat of wound, abdominal wall below 9th costal cartilage.] _Pari passu_ with the closure of the external openings, healing of the track takes place, but this is not always so rapid a process as is apparently the case. In many instances the closure, and even definite healing, of the external wounds is complete long before the track has actually healed, even though it be contracted up to complete closure as far as any cavity is concerned. This is well seen in many cases in which the exit opening is large as a result of deformation of the bullet, or the passage of bone splinters in conjunction with it; here, in spite of absence of all suppuration, the track may remain patent for many weeks. This may point to infection, but the tardiness in actual consolidation corresponds with what we are well acquainted with in the case of all aseptic wounds when a slough has to separate or become absorbed, and it is therefore only what might be reasonably expected when we remember that every such bullet track is lined by a thin layer of damaged tissue. [Illustration: FIG. 25 (_b_).--Great Omentum carried by the bullet into an exit track leading from the abdominal cavity. A. Outline of opening in the peritoneum] When fully healed, the points of entry and exit are so insignificant as to be less obvious than ordinary acne scars, and later are often hardly visible, but for a considerable period they are often more palpable than apparent. This depends upon the induration of the line of cicatrix corresponding to the course of the original track which is adherent to the two points. The induration is indeed so marked as to occasionally give rise to the suspicion that a foreign body such as a fragment of lead or of the mantle of the bullet has been enclosed during the healing of the wound. In the deeper portions of the tracks the extreme density of the cicatrix is a factor of great prognostic importance, since if it implicates muscles, tendons, vessels, or nerves, impairment of movement, circulatory disturbance, or signs of neuritis or nerve pressure are often witnessed. Thus, for instance, a track traversing the calf, will more or less tie the whole thickness of the structures perforated at one spot, and the apertures of entry and exit may be visibly retracted when the muscles are put in action with consequent pain and stiffness to the patient. Such pain and stiffness form some of the most troublesome after-consequences of many simple wounds. It is remarkable for how long a period after the healing of the wound and resumption of active duty the patients suffer from pain in and radiating from the locality of the wound, when fatigued or suffering from stiffness from the prolonged retention of one attitude or exposure to cold. The cords, however, eventually completely disappear, and the cicatrices become moveable. The effects of secondary pressure on the vessels and nerves are considered under the headings devoted to those structures. _Suppuration._--While the occurrence of deep suppuration or septic phlegmon was rare, local suppuration of the apertures of entry and exit was seen in a considerable proportion of the wounds. This was referable to infection from the skin itself, or to infection from without subsequent to the infliction of the injury. Infection from the skin, difficult to obviate at all times, is especially likely to occur in wounds the first dressing of which is often delayed, and which happen to men sweating freely into clothes the condition of which is at least undesirable for contact with a recent wound. Beyond this, the first dressing materials, removed from a soiled tunic by possibly a comrade or a stretcher-bearer, are scarcely above reproach of the probability of containing septic organisms themselves. Again, once applied, the exigencies of the situation often necessitate an amount of movement fatal to the retention of the dressing over the wound, and a second opportunity of infection arises before the patient comes into the hands of the surgeon in the Field hospital. The general tendency of such suppurations when they occurred in uncomplicated flesh wounds was to remain superficial, either involving the contused margin of the cutaneous opening and the plug of blood-clot occupying it, and resulting in a slight enlargement of the wound only, or at most involving the subcutaneous tissue and not extending into the deep planes of the trunk or limbs. In either case a slight delay in healing was the most serious result, while constitutional signs of infection were either absent or of the slightest nature. The same indisposition to spread by the track was equally noted when a deep portion became infected from, for instance, the intestine in a belly wound. Wounds of irregular type, however, such as those caused by ricochet bullets, or accompanying severe fractures, or those caused by fragments of larger projectiles, often suppurated freely in spite of exposure to no more unsatisfactory surrounding conditions than the wounds of small bore. This appears to show conclusively that the first element in the general slight consequences of small-bore wounds is their calibre, and, secondly, that increase of velocity on the part of the bullet, while it in some measure compensates for the loss of volume in the projectile, on the other hand reacts in favour of the wounded in so far as the injuries it effects on the soft tissues are ill suited to the development of septic organisms in the parts. _Retained bullets._--These were met with more frequently than might have been expected, but I can give no idea as to their proportional occurrence, since so many of the slighter injuries never came under my observation. Experience, however, showed that the bullets of large calibre and low velocity employed during the campaign were far more commonly lodged in proportion to the frequency of their use. Thus I saw a considerable number of Martini-Henry, Snider, large leaden sporting bullets, and shrapnel retained. Again, among the bullets of smaller calibre, the Guedes 8-mm. bullet, which travels at a comparatively low rate of velocity and with moderate spin, was far more frequently lodged than the Lee-Metford or Mauser in comparison with the number of Guedes rifles in use. Bullets of small calibre were, however, also retained with some degree of frequency, either as the result of striking at a long range, or in such a direction as to need to traverse a large segment of the body before escaping, or as striking large or several bones, or making some irregular form of impact: the last was a not infrequent explanation of lodgment, especially when a bone lay in the course of the track. Ricochet bullets naturally were especially likely to be retained, both on account of the low velocity with which they often travel and the irregularity of their surface with consequent loss of penetrating power. WOUNDS OF IRREGULAR TYPE Many of the wounds met with deviated so greatly in appearance and general characters from what has been described above as to afford little or no evidence of having been inflicted by small-calibre bullets, and before describing these it is necessary to give a short account of the circumstances which are responsible for such departures from the common type. In the case of the wound of entry, the simplest explanations are lateral impact on the part of the cylindro-conoidal projectile, due to the position of the part struck or the direction in which the bullet has been fired, wobbling on the part of the bullet due simply to loss of velocity and force in flight, or to turning of the bullet by impact with an obstacle to its course (ricochet) which may amount to actual reversal of the striking end. As a rule, in such cases the size of the aperture of entry exceeds that of exit, and in a large proportion the bullet is retained within the body. Of these explanations that of the 'wobble' needs some passing notice. In its simplest form it depends merely on loss of velocity of flight on the part of the bullet, the centre of gravity of which lies behind its middle; hence a tendency to turn over and over is acquired. As a result of this, either the side of the tip, the side of the bullet, the side of the base, or the base itself may form the portion of the projectile which comes into contact with the body. The tendency to wobble is naturally greatly increased in ricochet bullets, since the contact, if lateral, serves to check the spin on which the bullet depends for its flight on an axis parallel to its long diameter. The first effect of wobbling is to increase the size and interfere with the regularity of outline of the wound of entry; but it also acts in a more serious manner, since the increase of the area of impact augments the resistance offered by the body; therefore the degree of damage to the tissues is accentuated and becomes greater than it would be from a bullet travelling at the same rate on its normal axis. Hence the wounds are both large and severe, or if the velocity is very low, the projectile is especially likely to be retained. Actual reversal of the bullet usually only slightly enlarges the aperture of entry, but injuries to cancellous bone are apt to be more severe when the bullet enters in this manner, or again it is often retained. I saw several such cases during the campaign. Another form of wobble is suggested by Nimier and Laval,[9] of which I can offer no experience. They suggest that, as rotation slows, the bullet may on impact wobble like a top before it ceases to spin. Probably the power of penetration possessed by a bullet wobbling in this manner would not be very great, but its effect would mainly be altered in the direction of an abnormal increase in the size of the aperture of entry, or possibly in the degree of comminution in fractures. It is probable that some of the more serious wounds observed were merely the result of unusual forms of impact with normal flight on the part of the bullet. The majority, however, depended, in the case of the wound of exit, on deformation of the bullet within the body, or the propulsion of bone fragments with it, and, when both apertures were affected, to previous ricochet on the part of the projectile. It is here necessary to give a short account of the more common deformities met with, and to refer to the special characters possessed by different types of bullet of small calibre which may affect the ease with which deformity is produced, and the degree to which it is commonly carried. The effect of ricochet is to lower the velocity of flight, and at the same time to effect certain alterations of form in the bullet. These with rectangular impact in the case of bullets travelling at a low degree of velocity consist in a bending and deformation of the tip; in the higher degrees, of bending, shortening, extensive destruction, or complete fragmentation. If the bullet makes lateral impact, only widening and flattening result, often with the escape of the lead core from the mantle. That a ricochet bullet may travel a considerable distance is shown by the following observations quoted from Nimier and Laval.[10] [Illustration: FIG. 26.--Sections of four Bullets to show relative shape and thickness of mantles. From left to right: 1. Guedes; regular dome-shaped tip; mild steel mantle; thickness at tip 0.8 mm.; at sides of body 0.3 mm. 2. Lee-Metford; ogival tip; cupro-nickel mantle; thickness at tip 0.8 mm.; gradual decrease at sides to 0.4 mm. 3. Mauser; pointed dome tip, steel mantle plated with copper alloy; thickness at tip 0.8 mm.; gradual decrease at sides to 0.4 mm. 4. Krag-Jörgensen; ogival tip as in Lee-Metford; steel mantle plated with cupro-nickel; thickness at tip 0.6 mm.; gradual decrease at sides to 0.4 mm. The measurements of the sides are taken 2.5 cm. from the tip. Note the more gradual thinning in the Lee-Metford mantle.] Up to a distance of 1,700 to 1,800 metres the bullet may make several ricochet bounds. When the bullet strikes first at short distances (as 600 metres), it may make several bounds of from 300 to 400 metres: at moderate distances (as from 600 to 1,200 metres), bounds of 200 to 300 metres; and at distances above 1,200 metres, bounds of 100 to 200 metres. The length of the ricochet bounds depends on the angle of impact of the bullet with the ground, the nature of the slope of the latter, and the velocity of the bullet. Putting aside the question of calibre and volume of the bullets we are concerned with, I believe the most important variations as serious effects of ricochet depend on the relative thickness and the composition of the mantles. Fig. 26 illustrates the relative thickness of the mantles in the Krag-Jörgensen, Mauser, Lee-Metford, and Guedes bullets. Given an equal degree of force and velocity on the part of the bullet at the moment of impact, the assumption is justifiable that the thinner mantles would tear or burst more readily in direct ratio to their relative thinness. I believe this assumption to be borne out by my own experience of the common deformities that occurred; but the great relative frequency with which Mauser bullets came under my observation, and the difficulty of forming any estimate of the velocity and force retained by any particular bullet at the moment of impact, make it impossible for me to express myself with the confidence which I should wish. [Illustration: FIG. 27.--Normal Mauser Bullet] The second condition which influences the nature and degree of the deformities depends on the relative tenacity or brittleness peculiar to the metal employed in the manufacture of the mantles. In the case of the Lee-Metford this consists of an alloy of 80 parts of nickel with 20 of copper. The Krag-Jörgensen and Mauser are ensheathed in steel plated with cupro-nickel, and the Guedes has a plain steel envelope coated with wax. Both as a result of experience in the field gained from ricochet bullets, and in the hospitals from bullets which had undergone deformation within the body, I am under the firm impression that the thin nickel-plated steel envelope of the Mauser bullet splits more readily than the thicker and more tenacious cupro-nickel envelope of the Lee-Metford, that the direction of the ruptures is more purely longitudinal, and the fissuring itself more extensive and complete. I append below a series of deformities observed in Mauser bullets, some of which were collected on the field of battle, but all of which were familiar to me in bullets removed from the bodies of patients, except the complete disc shape shown in fig. 29. They correspond with specimens of which I made sketches at the time of removal from the body, but which I had not the heart to retain in view of the natural wish of the patients to keep them as mementoes of their wounds. [Illustration: FIG. 28.--Four common types of lateral Mauser Ricochet Bullets. From left to right: 1. Slipper form; slight broadening and turning of tip. 2. More pronounced degree of form 1, with laceration of the mantle opposite the shoulder of the bullet. This is the weakest spot, for two reasons: the alteration in curve at this position, and the junction of the thickened point of the mantle with the thinner sides. 3. Lateral ricochet involving nearly whole length of bullet. Rupture of mantle from broadening of core opposite shoulder. 4. Similar lateral ricochet with extensive longitudinal rupture of mantle, the latter being turned out and forming a cutting 'flange.'] Slight indentations and deviations from strict symmetry of form of such degree as not seriously to influence the outline and nature of the apertures were very common. Beyond these one of the most frequent primary deformities was that we familiarly spoke of as the 'slipper form' (No. 1, fig. 28). This results from light glancing contact of the tip with a hard body: in it the mantle of the bullet is rarely fractured, and the deformity itself is of slight importance, except in so far as it may influence the direction of the wound track, which acquires a tendency to be curved. The tip of the bullet is slightly flattened and turned up, down, or to one side, according to the point struck. I saw this deformity frequently, both with Lee-Metford and Mauser bullets. Nos. 2, 3, and 4 are more pronounced degrees of the same type of deformity, accompanied by more or less extensive fissuring of the mantle. No. 4 illustrates the turning out of the longitudinally fissured mantle in such a way as to make a cutting flange. I have seen such bullets removed, and the variety is of some importance as materially increasing the cutting capabilities of the bullet, and augmenting its area of destructive action. No. 5, fig. 29, is the only form I have not seen removed, but such a bullet would account for some of the long irregular gutter wounds observed, if it retained sufficient velocity to strike with any force. [Illustration: FIG. 29.--'Disc'-shaped Lateral Ricochet. This form is of little practical importance, as the velocity retained by the bullet is low, and no perforating power would be retained. It is inserted separately in order to complete the series, shown in fig. 28.] Fig. 30 illustrates complete longitudinal fissuring of the mantle. Such mantles are common, and still more so are the opened-out sheets such as is shown still attached in fig. 29. Free mantles are often very numerous on stony ground, but are of little importance, since I never saw fragments of them removed or impacted. They probably travel a very short distance after their formation, and if they did strike would possess little power of penetration. The freed leaden cores do, however, sometimes enter the body, and some of the specimens removed have been referred to the use of expanding bullets. In all the Mauser specimens the longitudinal direction of the fissuring of the mantle is striking. [Illustration: FIG. 30.--Ruptured Mauser Mantle, to illustrate the tendency to complete longitudinal fissuring] Fig. 31 represents bullets removed from the body and illustrates types of deformity due to impact with the bones. The deformity resembles in some degree that of the mushroomed lead cores, and also indicates that the shoulder of the cased bullet is its weakest point. Each specimen exhibits shortening and widening without fracture of the mantle, the latter being simply thrown into folds; both bullets were lodged in the thigh after fracturing the femur. The localisation of injury to the fore part of the bullet, and the fact of expansion, allow us to infer that the degree of velocity retained on impact with the bone was comparatively low, and that neither bullet had been exposed to very severe strain. [Illustration: FIG. 31.--Two retained Mauser Bullets which had produced comminuted fractures of the femur of moderate severity. Each has given way at the shoulder, but the mantle has developed creases without rupture, and the bullets are correspondingly bent. Both bullets were travelling at a moderate if not low degree of velocity] Fig. 32 is also of a retained bullet in which the fore part of the mantle is very extensively fissured and the core set free. In this the mantle has suffered severely and the leaden core to a less extent. As an apical ricochet it corresponds with the Lee-Metford shown in fig. 36. [Illustration: FIG. 32.--Apical Ricochet Mauser Bullet (see text). The 'mushrooming' of the core is moderate, but the destruction of the anterior part of the mantle very considerable] The deformity found in fig. 32 I met with both in retained bullets and also in those which had been fired into sand or anthills. The particular specimen figured was removed from the thigh of a patient wounded at the battle of Belmont. An irregular entry wound was situated over the internal tuberosity of the tibia, while a large fluctuating hæmatoma existed in the lower third of the thigh, at the upper part of which a hard elongated body was palpable. As was so often the case with internal hæmorrhages, the patient's temperature rose high, and on the third day the hæmatoma was incised by Major Coutts, R.A.M.C. The core of the bullet was then found in the blood cavity near the surface, but on introduction of the finger a second body was discovered entangled in the quadriceps muscle, and this proved to be the tattered mantle. I saw similar deformity produced within the body by a bullet, which, entering by a small type aperture in the left ala of the nose, struck the margin of the right malar bone, and lodged beneath the latter. The similarity of this bullet to that seen in the ricochet in fig. 32 was exact. The form is of great importance both on account of the degree of laceration it effects in the track, the presence of two foreign bodies in the wound, and from the fact that it can be produced by making the bullet travel through sand or antheaps, since both the former in the shape of sandbags and the latter in their natural state so often formed the cover to men during the campaign. Bullets of 6.5 mm., such as the Krag-Jörgensen, with steel envelopes apparently break up with great ease in sand. Fig. 33 shows a form not uncommon when the bullet comes into contact with the ribs. It is produced in bullets travelling at a low rate of velocity and striking by their side. I several times met with it when the bullet was retained, and also without fracture of the rib. In some variety it might occur after impact with any narrow margin of bone, and some importance attaches to the form, since it affords evidence as to the ease with which alterations in symmetry can be produced in Mauser bullets. Again its bent outline favours deviation in the further course of the bullet subsequent to impact with the bone, a result which I observed on more than one occasion. [Illustration: FIG. 33.--Grooved Mauser removed from anterior abdominal wall after crossing the ribs. I saw several such removed from the thoracic wall, and am inclined to attribute the grooving to impact with the margin of the ribs] Lastly, the question of actual spluttering or breaking up of the bullets must be considered. It is extraordinary into how many fragments either a Lee-Metford or a Mauser bullet may break up if it strike a hard body while travelling at a high rate of velocity. Fragmentation is exhibited in the skiagram forming the subject of plate XI. p. 194. It is somewhat remarkable how often this occurred when the short hard bones of the metacarpus were struck. With regard to the casing, the separation of small scales of the nickel plating has already been referred to; reference to the skiagrams, plates IX. and XVI., shows how readily the whole thickness of the mantle breaks up into small fragments, even when the bullet is travelling at moderately low degrees of velocity, and this I believe to be a special characteristic of the thin cupro-nickel-plated steel mantles. Any variety of cased bullet, however, when it strikes against a stone, hard ground, or a bone, may be broken into innumerable fragments. The leaden fragments occasionally show a simple fractured surface, such as is illustrated on a larger scale by the broken shrapnel bullets shown in fig. 96, p. 485. More commonly, however, the fragments, if of any size, appear torn, and if small, are mere spicules. These if of lancet shape often bury themselves in the skin only, while larger ones may penetrate deeply or even perforate. Thus, of a group of three officers standing near a stone on which a bullet struck, all were spattered about the face; most of the fragments lodged in the skin, but one perforated the concha of the ear and bruised the mastoid area, while others caused small jagged cuts. In another instance, both thighs of the patient were spattered after perforation of the clothes, and a large fragment lodged beneath the skin of the penis. A case in which larger fragments perforated and simulated type wounds has already been referred to on p. 44. [Illustration: FIG. 34.--Normal Lee-Metford Bullet] The above remarks apply, for the most part, to Mauser bullets only, because my experience of that projectile was far wider than of the Lee-Metford. The only deformed Lee-Metford bullets that I saw removed from the body were of the 'slipper' variety, exactly corresponding to the similarly altered Mausers, and with no fissuring of the mantle. I saw none so freely deformed as the Mausers depicted in figs. 28, 29, 31, and 32. In spite of diligent search on several battlefields, I was unable to collect many forms of Lee-Metford ricochet, although I found many undeformed bullets. I insert here, therefore, some illustrations I obtained through the kindness of Colonel Hopton, Director of the School of Musketry at Hythe, which are of interest, and in some degree substantiate the impression I formed in South Africa as to the greater stability of the Mark II. Lee-Metford bullet (fig. 34). I am aware that, as meeting a smooth target at right angles, some of these are not strictly comparable to the Mauser bullets forming the subjects of the preceding illustrations, which struck stones, and these mainly by their sides (if we except figs. 31 and 32), but they sufficiently exhibit the characters on which I wish to insist. That they support my opinion is the more probable as, with the exception of the type included above, I am under the impression that the large majority, if not all, of the Mauser bullets which struck stones fairly with their tips were broken to pieces, otherwise I must have met with some among the immense number which I saw. On the top of Tabanyama, for instance, the whole ground was littered at the time of my visit with shattered mantles and leaden cores, deformed almost past recognition. [Illustration: FIG. 35.--Apical Lee-Metford Ricochets. From Hythe targets. Tendency of cupro-nickel envelope to tear in transverse direction] The specimens depicted in figs. 35 and 36 indicate--(1) a greater malleability on the part of the mantle; thus in fig. 35 the cupro-nickel is obviously hammered and flattened out, while the fissures are neither numerous nor extensive. (2) Both bullets exhibit transverse tearing of the mantle, a common feature in Lee-Metford ricochets, of which I could offer other examples, but which I less often observed in Mauser bullets. (3) Tear is the term best expressing the nature of the fissures, while fracture more nearly expresses the nature of the fissures in the Mauser mantles. (4) Fig. 36 shows a mushroomed core and split mantle, which may be compared with the similarly deformed Mauser depicted in fig. 31. I think the variation in appearance is characteristic, the fissuring of the mantle being much less extreme, while the leaden core is normal at its base in consequence of the support afforded by the more tenacious cupro-nickel mantle. With regard to complete splitting of the mantles, however, I must add that free Lee-Metford mantles are often found from bullets fired at the target or elsewhere, and Nimier and Laval figure numerous forms.[11] [Illustration: FIG. 36.--Apical Lee-Metford Target Ricochet. Well-marked 'mushrooming' of core. 'Torn' nature of the fissures in the mantle and limited extent. Compare with fig. 32] _Expanding bullets._--The wounds resulting from perforation with deformed regulation bullets, such as are described above, differ for the most part by deviation from the type appearances, and a tendency to take a less favourable course on account of their increased size and of the greater degree of laceration of the tissues accompanying them. I must now pass on to the consideration of the forms of bullet especially likely to occasion those wounds spoken of as 'explosive' in character, and my remarks on these must be prefaced by a short description of the varieties which were in use during the campaign. [Illustration: FIG. 37.--Four Soft-nosed Bullets from Boer trenches. From left to right: 1. Mauser (.275); small amount of core exposed. 2. Lee-Metford (.303). 3. Lee-Metford, with larger amount of exposed core, also cupped apex. This is probably the most effective of these forms. 4. Mannlicher (.315)] These consisted in soft-nosed bullets of the Mauser and Lee-Metford patterns, Tweedie and Jeffreys modifications of the Lee-Metford and Mauser, several soft-nosed bullets of a slightly larger calibre, mostly old Mauser or Mannlicher types, and a large variety of sporting leaden bullets of larger calibre and volume. Figs. 37 and 43. With regard to the various soft-nosed bullets of small calibre, I will first advert to a feature common to all, which consists in a solid base to the mantle. In the regulation whole-cased bullets the leaden core is inserted from the base, and the edge of the mantle is then so turned over for fixation purposes as to leave the central portion of the lead exposed. The position of the exposed portion of the core is therefore reversed in the two varieties. The small experience I had the opportunity of obtaining was all to the effect that the solid base considerably increases the stability of the mantle, and I never saw the latter seriously torn in any specimen either collected on the field or removed from the body. [Illustration: FIG. 38.--Two Soft-nosed Lee-Metford Bullets (see text). 1. Removed from forearm. 2. Removed from beneath skin of back after it had perforated the scapula. In both the velocity retained was no doubt low, and neither encountered great resistance] Fig. 38, 1, represents a soft-nosed Lee-Metford removed from just below the lesser sigmoid cavity of the ulna, after it had perforated the elbow-joint. The soft nose appears to have been torn, and separated by impact with the bone, but the mantle is little altered. There can be little doubt, however, that the bullet was travelling at a comparatively low rate of velocity, since it was retained in the forearm, whence its various parts were removed by Major Lougheed, R.A.M.C. I picked up a number of similarly deformed bullets on the field. No. 2 represents a soft-nosed Lee-Metford which perforated the scapula from the front; the bullet was retained, hence again velocity cannot have been very high, and the comminution was slight. If it had passed out, a large exit wound would, however, have resulted. [Illustration: FIG. 39. Soft-nosed Lee-Metford Mantle. Lateral ricochet. Illustrating effect of solid base in maintaining the stability of the mantle] Fig. 39 represents a type of ricochet sometimes found on the field. In spite of a considerable amount of violence which has caused the escape of the core, the fissuring of the mantle is comparatively slight. In point of fact, the casing is, as a rule, preserved from the severe violence it suffers when complete, by the flattening and turning over of the soft nose. I am sorry I cannot append an illustration of a damaged soft-nosed Mauser, but I am of opinion that those used during the campaign were not of a very dangerous nature on account of the small amount of lead exposed. To gain the full advantage of the soft nose at least a third of the core should be exposed. No. 3, fig. 37, of a Lee-Metford, probably represents the most effective form of such bullets. I am inclined to think these bullets as a class, however, are not more dangerous to the wounded man than the regulation Mauser fired at short range, if the latter either comes into contact with bone or suffers ricochet. The Tweedie and Jeffreys bullets come under a somewhat different category. In the Tweedie the top of the bullet is sawn off in such a manner as to flatten the tip and widen the surface of direct impact, and to expose the leaden core over a small area. The general principle of the flat tip resembles that of the French Lebel bullet. In the Jeffreys modification the mantle is sawn down for about half the length of the whole mantle, the slits neither reaching tip nor base. I seldom saw these bullets removed, but they were used to a considerable extent. Fig. 40 illustrates one of Mauser calibre in the possession of Mr. Cuthbert S. Wallace. It perforated the abdomen, producing fatal injuries, but the only alteration in outline consists in slight bulging and shortening. This specimen, however, manifestly suffered but slight resistance. A somewhat general impression existed that a number of severe injuries had been produced by the Jeffreys bullets, but it was a matter of conjecture, as few of them were removed. A weekly illustration appears in the advertisement sheet of the 'Field,' showing the deformity of some of them shot into animals, which bear a strong resemblance to the Mauser figured earlier (fig. 31), and which we have seen can be produced in the human body by contact of a regulation fully cased bullet with a bone like the malar. A tendency on the part of the longitudinal slits to become caught in the rifling of the barrel militates against the use of this bullet. [Illustration: FIG. 40.--Jeffreys modification of Mauser. The bullet is in the possession of Mr. C. S. Wallace. It perforated the abdomen and caused death. The bullet is only slightly shortened by bulging at the shoulder] [Illustration: FIG. 41.--1. Section of Mark IV. Lee-Metford. Note thickness of mantle and exposed core at base. 2. Soft-nosed Mauser. Note solid base. Short pattern] Fig. 41 represents sections of the soft-nosed Mauser, and the British Mark IV. bullet, and shows the different method of closure of the base. If the former remarks on the influence of the closed base in maintaining the stability of the bullet be correct, Mark IV. should be a very destructive bullet. I have no experience of its use, but I am inclined to think that here, as elsewhere, the thickness and resistance of the cupro-nickel mantle would endow it with considerable stability, unless it met with very great resistance. [Illustration: FIG. 42.--Types of Bullets tampered with by the Boers in the trenches. 1 and 3. Cross-cut tips, Martini-Henry and Lee-Metford. 2. Groove cut at base of exposed tip of Lee-Metford. Another modification of the Martini-Henry consisted in boring it longitudinally and inserting a wooden plug] In connection with the subject of soft-nosed bullets, I should mention that the Boers occasionally extemporised various modifications of them, such as are shown in fig. 42, with intent to increase the wounding power of the projectiles. I am unable, however, to give any information as to the effects produced by these, and I do not think they were often employed. The illustrations are from cartridges found in trenches which had been occupied for some time by the Boers, who had no doubt used their spare time in exercising their ingenuity on the bullets. 'Explosive' bullets of small calibre were also said to have been employed; with regard to these I can only say that I never met with any example of a hollow bullet containing explosive material. One officer in a Colonial corps who spoke freely about them, told me he had 'sawn' them in half and found the cavities, but the method of investigation he had employed seemed against the presence of any fulminant in the body of the bullets. Others based their statements on the fact that they had frequently heard the bullets burst in the air; but this is probably to be explained by the breaking up of regulation bullets on impact with stones, which makes a smart crack like a small explosion. A clip of soft-nosed Mauser cartridges, in which a copper centre to the bullet suggested a percussion-cap, was sent home to the War Office. Colonel Montgomery has kindly furnished me with the following report on the bullet: 'The bullet contains no explosive matter, it is fitted with a hollow copper tube in the nose, similar to the ordinary "Express" bullet. The envelope is made with a solid base, which is possible in this bullet owing to the core being inserted from the front.' One cannot help feeling some astonishment at the strong feeling that has been exhibited regarding the use of expanding bullets of small calibre, both at the Hague Conference and during this campaign, when the Martini-Henry, a far more dangerous and destructive missile in its effects at moderate ranges, is allowed to pass muster without notice. Lastly, we come to bullets of large calibre unprovided with a mantle. The Martini-Henry is practically representative of all these, but I append a photograph of some twenty out of thirty varieties which came into my possession during searches amongst captured ammunition. Some of these were provided with a copper core to facilitate 'setting up,' others were cupped at the top, and others flattened, to increase the resistance on impact. I can say little about them except that I believe some of the forms were responsible for a considerable proportion of the most severe injuries we met with, in some of which a large and regular entry made their use certain, while a considerable proportion of them were retained. In the case of the viscera their power of doing serious damage was very striking compared with that of the bullets of small calibre. As with the small sporting bullets I think their use was often due to the fact that the sporting Boer preferred to use the weapon he was accustomed to rather than his military weapon. A considerable number of the Boers were armed with Martini-Henry rifles, and this was particularly the case with small bodies of men, rather than with the larger commandos fighting regular engagements. The Transvaal Government, moreover, had Martini-Henry rifles made as late as 1898. The Martini-Henry bullet was responsible for some of the worst fractures that came under my notice, but it is of interest to remark that its capability to do damage did not satisfy some of the Boers, who cut them as is shown in fig. 43. I cannot say what the effect of this manoeuvre was, although it may have accounted for some of the wounds of the calf such as are mentioned below. Some odd missiles were met with during the campaign; thus, at Ladysmith, I was told ball bicycle bearings were at one time in use amongst the Boers. _Anatomical characters of wounds of irregular type._--It will be seen from the above that in dealing with wounds of irregular type we have to consider those due to irregular impact of normal regulation bullets, to bullets deformed by contact with bone, to ricochet bullets, and lastly to bullets of the expanding type. No further mention of those due to irregular impact is needful beyond what has already been said under the heading of wobbling, except to point out that, given a fair degree of velocity, these injuries may assume an actual explosive character, especially in the case of skull fractures. The description of extensive wounds accompanying comminuted fractures finds its most appropriate place under the heading of injuries to the bones, and will be there considered (Chapter V. p. 155). 'Explosive' exit apertures are, however, described as occasionally occurring in injuries involving the soft parts only. I saw no cases substantiating this belief, but several were described to me as having been met with in abdominal injuries, which terminated fatally at an early date. [Illustration: FIG. 43.--Four Soft-nosed Bullets of small calibre shown in fig. 37. Twenty large-calibre leaden carbine and rifle bullets from cartridges found in Boer arsenals. These were not very extensively used, but specimens of most varieties were at times removed from our wounded men. It will be noted that some are of great weight, and a large proportion either cupped or flattened at the apex to increase area of impact and consequent resistance. The 'express' bullet with a copper core is included in this series. It is worth remarking that all the bullets of this nature in the Pretoria Arsenal were waxed, and that the wax retained its white colour on the lead.] I still, however, incline to the opinion that the bullet in these cases had come into contact with some bone, or was one of the larger varieties of projectile. A few cases of wound of the calf did, however, come under my observation which presented fairly typical 'explosive' characters without evidence of solution of continuity of the bones. I will shortly recount two of them. In the first the exit opening was very large and on the outer aspect of the limb in the upper third. The bullet had apparently passed between the bones. Secondary hæmorrhage from the anterior tibial artery necessitated exploration of the wound and ligature of the vessel (Mr. Carré). When the wound was thus laid open no injury to the bones could be detected, but I do not consider that it could be actually excluded. In the second case a wound traversed the calf transversely, just above the centre; the exit aperture was large and ragged. Deep suppuration occurred, and the wound had to be laid open, when a fracture of the tibia without solution of continuity was discovered. I also saw one or two wounds of the buttock in which very large exit apertures were present with small entry openings; in these again it was impossible to exclude passing contact of the bullet with a part of the pelvic wall. Unfortunately in all these cases it is impossible to obtain the bullet responsible for the injury. In this relation I append a diagrammatic illustration of a peculiar wound shown to me by Mr. Hanwell. In this case a typical small entry wound was situated at the outer margin of the left erector spinæ muscle in the loin. The bullet had taken a subcutaneous course of not more than three-quarters of an inch, while the exit opening was a long shallow wound measuring 4-1/2 in. in length by 1-1/2 in. width. (Fig. 44.) The wound was stated to have been received at a distance of from fifty to a hundred yards. I think we can scarcely assume that impact with the margin of the erector spinæ could have resulted in 'setting up' of the bullet, while an irregular tongue of skin at the point where the wound crossed the spines of the lumbar vertebræ did suggest possible bony contact. That the latter must have been of the slightest nature is evident, as no signs of concussion of the spinal cord were noted. I should rather be inclined to compare this case to one of gutter wound quoted on p. 56, and to assume that the bullet passed so closely beneath the surface as either to entirely sever the skin, or at any rate to allow it to give way on flexion of the back on movement. [Illustration: FIG. 44.--Small Circular Entry, large 'explosive' skin wound of back. Track only an inch or less in length (see text)] On the ground of the observations made in the foregoing pages it will be gathered that the opinion I formed was against either the very free use or the great wounding power of so-called expanding bullets of small calibre. I believe that a great number of the injuries which were attributed to the employment of these missiles were produced either by ricochet regulation bullets of small calibre, or by large leaden bullets of the Martini-Henry type. _Symptoms._--I very much doubt whether the general symptoms observed as the result of wounds from bullets of small calibre differ in more than slight degree from those described when larger bullets were regularly employed. Great variation was met with, but I do not think a diminution in serious results in this direction corresponding to the comparatively limited nature of the direct injury to the organs or tissues can be affirmed. It is true that the immediate symptoms in many patients were amazingly slight, but after all, this has always been a feature of gunshot injuries on the field of battle and cannot be assigned a position of distinctive importance. 1. _Psychical disturbance and shock._--Some remarkable instances of psychical disturbance were observed, and although perhaps in no way influenced by the calibre of the projectile, they seem worthy of note in this place. Thus a patient wounded over the cervical spine and who suffered later with a slight degree of spinal concussion emitted an involuntary shriek like that of a wounded hare on being struck; another (Martini wound), after receiving a wound of the chest, lost all sense of his surroundings for a considerable period, and occupied himself in attempts to write on a white stone lying near him on the veldt; then suddenly realising his position he was greatly bewildered in trying to account for his own action. A similar instance of preoccupation is probably offered by the dead man in the accompanying photograph (fig. 45), whose arms, forearms, and hands had evidently been in play until the actual moment of death. Again the influence of the psychical state on the actual occurrence of shock was often illustrated by the mental condition of the wounded after a battle; thus after the battles of Belmont and Graspan the patients came into hospital in excellent spirits, and minimised their injuries in the wish of rapidly regaining the front; while after the battle of Magersfontein the men were depressed and miserable, shock was more pronounced, and their sufferings were undoubtedly greater. On the whole, however, shock was by no means a prominent symptom in the small-bore injuries of soft parts, and was possibly less than when larger bullets were the rule, and again it was often remarkably slight after the infliction of serious visceral injury. Still shock was observed in a considerable proportion of the patients, and its occurrence appeared to vary under very much the same conditions as obtain in civil practice. Grades of severity depended on individual idiosyncrasy, on the degree of excitement or preoccupation at the moment of injury, and to a certain degree on the range of fire at which the injury was received. [Illustration: FIG. 45.--Note position of head, neck, and forearms in upper figure] The last is the only special factor, and as far as my observation went it was one of considerable importance. When the soft parts only were affected, even high velocity did not produce much effect; but when to a flesh wound a severe bone fracture or injury to any part of the nervous system was added, shock might be severe or profound. The question of shock dependent on visceral injury will be considered in succeeding chapters, but it may be well to state here that the most severe shock appeared to follow injuries to the central nervous system especially to the spinal cord, fracture of the larger bones, and wounds of the abdominal and thoracic viscera, the latter especially when the cardiac neighbourhood was encroached upon: hence the severity depended almost solely on the importance of the part injured and the degree of damage inflicted. I never observed instances of entire absence of shock in visceral injuries, unless the range of fire had been an especially long one. To these remarks on constitutional shock I should add a few on the 'local shock' exhibited by the actual part of the body struck. The phenomena were of a severity I was quite unacquainted with in civil practice, and apparently were attributable to the local vibration transmitted to the whole structure of a limb or part of the trunk. In many fractures, and in some wounds of the soft parts alone, without the direct implication of any large nerve trunk, the loss of functional capacity of the limb was complete, and this condition persisted for hours or even days. 2. _Pain._--As an initial symptom the occurrence of pain varied greatly with the idiosyncrasy of the patient, and according to the circumstances under which the wound was received. Some individuals are remarkably insensitive, and in these the fact of a wound being a gunshot injury in no way altered their habitual insensibility, but in persons of what may be termed the normal type in this particular great differences were observed. When a wound was received in the full excitement of battle during a rapid advance, pain was often slight, or so trifling in degree that it was almost unnoticed; many patients did not realise that they had been struck until a second wound, possibly implicating a bone or some specially sensitive structure, was superadded. In such instances the pain was often described as 'burning' in character, or even likened to a 'sting from an insect.' Occasionally the pain was referred to a distant part; thus a man struck in the head first felt pain in the great toe, and another struck in the abdomen also felt pain in his foot only. Again in some multiple injuries, pain was only felt in the more sensitive of the regions implicated; thus a patient in whom a bullet (Martini) traversed the arm and chest emerging in the neck to again enter the chin and comminute the mandible, only felt pain in the chin and first realised that he had been wounded elsewhere when he undressed. A striking instance of the entire absence of initial pain was afforded by a man shot through the buttock, the bullet then traversing the abdomen: this patient remained unaware that he had been hit until on undressing he found blood in his trousers and exclaimed: 'Why I have got this bloody dysentery!' None the less his internal injuries were sufficiently severe to lead to death during the next thirty-six hours. Although initial pain might be slight or absent, practically all the patients complained of some of varying severity at the end of an hour after reception of the wound. In a large proportion of the wounded, however, pain was more or less severe from the first, and this was especially the case when the men had been exposed to fire for some hours behind inadequate 'cover.' The most common descriptions under these circumstances were that they felt as if they had been struck by 'a brick,' 'a ton of lead,' or 'a sledge-hammer.' 3. _Hæmorrhage._--This question is fully treated under the heading of injuries to the blood-vessels. It will suffice here to say that hæmorrhage was rarely of a dangerous nature so far as life was concerned, unless the large visceral vessels or those in the walls of serous cavities were concerned, when death was often rapid. From limb wounds, even when the largest trunks were implicated, the general tendency was to spontaneous cessation of the hæmorrhage. Consequently, except these patients were seen on the field, one seldom had to deal with serious bleeding. None the less, the condition of the patients' clothes bore testimony to a free rush immediately after the injury, and pools of blood were occasionally found where patients had lain. In nearly all cases the rush of the bullet determined the initial flow of the blood from the exit wound, and this aperture usually furnished any hæmorrhage of importance. _Diagnosis._--The only diagnostic point which it is necessary to consider in this chapter is the determination of the nature of the bullet which has caused the particular injury under observation, and this is more a matter of interest than importance. The primary indication lies in the size of the aperture of entry, which naturally varies with the calibre of the bullet employed, and the difference, except in the case of large projectiles, is not always easily determined, unless we can be sure that the impact of the bullet was at right angles. In the latter case it is possible to distinguish even between, for instance, a Lee-Metford and a Mauser wound, if the resistance likely to be offered by the part struck is kept in mind. A ricochet bullet, on the other hand, may upset all our calculations, if size alone be taken as an indication; but here the irregularity of the wound often serves to exclude one of the larger varieties as the cause. The appearances of the exit wound are less useful in determining the nature of the bullet employed, as irregularities of outline are so much more common whatever projectile may have emerged; but examination of this wound often gives us useful information as to the existence of an injury to the bones not involving loss of continuity. [Illustration: FIG. 46.--Two flattened Leaden Cores to illustrate means of determination of nature of bullet. Note ring at base. The right-hand bullet is probably a 'man-stopping' revolver bullet; it flattened against bone] Other information beyond that furnished by the external wounds may be gleaned from the presence of fragments of lead in the wound; these, if unaccompanied by portions of casing, afford some presumptive evidence of the use of an unsheathen bullet, especially if found on the fractured surface of the bones; but it must be borne in mind that in the case of ricochet bullets the leaden core often perforates when entirely freed from its mantle. Pieces of the mantle again may give useful information both from examination of their thickness and composition. Lastly a naked core nearly always retains the marking on its base corresponding to the turning over of the mantle, this not being likely to suffer impact calculated to efface the groove. When this groove existed the employment of any of the soft-nosed bullets used in this campaign might be safely excluded (fig. 46). _Prognosis._--The question of general mortality amongst the wounded has already been considered (Chapter I. p. 11), and it has been shown, putting aside those dying at once on the field, or during the first twenty-four hours, that the mortality was a low one. Some other points specially dependent on the nature of the injury are, however, worthy of mention in this place. First, it has been shown, with a slight reservation as to when a wound can be considered definitely sound, that if suppuration did not occur, healing was rapid, and that many men with slight wounds were back with their regiments in the course of a very few days. Again, that suppuration when it did occur tended to be local in character; none the less, if it was at all extensive, it often proved very prolonged and difficult of treatment, while residual abscesses after apparent healing were not uncommon. In connection with this subject I may quote from Colonel Stevenson[12] an observation that limbs the subject of marked local shock are especially liable to furnish septic discharges. Parts the subject of local shock when infected show a lesser degree of vitality and power of resistance to the spread of infection than do normal ones, and if infected do badly. I think I convinced myself of this on many occasions, and also of the fact that cases of fracture in which this condition was marked were slow in consolidating. Again I am inclined to think that the bad results which sometimes followed the tying of the limb arteries were also consequent on lowered vitality, and possibly vaso-motor disturbance due to the effects of the exquisite vibratory force to which the nerves had been subjected. On this account I was never anxious to hurry operations in such cases, unless obviously necessary at the moment. The larger question of general nervous breakdown as the result of injuries from bullets of small calibre is at present hardly capable of an answer, and is so complicated by the co-existence of concurrent mental anxiety, exposure, &c., that a definite answer will always be difficult. I think there is already sufficient evidence, however, to suggest that the remote effects of many of these injuries may be far more serious than we expected at the moment, especially in the direction of sclerotic changes in the nervous system. _Treatment_.--In view of the remarks on the treatment of special injuries contained in succeeding chapters, I shall confine myself here to the question of the treatment of wounds of the soft parts alone. This consisted during the campaign in the primary application of the regulation first field dressing by one of the wounded man's comrades, an orderly, or less commonly an officer or a medical man. This dressing is composed of a piece of gauze, a pad of flax charpie between layers of gauze, a gauze bandage 4-1/2 yards long, a piece of mackintosh water-proof, and two safety pins, enclosed in an air-tight cover. Mr. Cheatle,[13] in insisting on the importance of an immediate antiseptic dressing in the field, recommends the following. A paste contained in a collapsible tube, made up in the following proportions: Mercury and zinc cyanide grs. 400, tragacanth in powder gr. 1, carbolic acid grs. 40, sterilised water grs. 800; sufficient bicyanide gauze and wool for the dressing of two wounds, a bandage, and four safety pins; the whole enclosed in a mackintosh bag. The paste possesses the advantage over any liquid or powder, that it can be applied in any position of the body to severe wounds, and its application in the open air is not interfered with by draughts of wind. Mr. Cheatle used a similar preparation with success during the campaign. On arrival at the Field hospital, or in some cases at the station of the bearer company, the wounds were then commonly dressed as follows: The parts around the wound were cleansed with an antiseptic lotion, either solution of perchloride of mercury 1 in 1,000, or 2-1/2 per cent. solution of carbolic acid. The wound itself was then cleansed, and a dressing of double cyanide of mercury and zinc applied. This was covered with a pad of wool and secured with a bandage. The gauze was usually wrung out in the lotion before application as a precaution against previous contamination, and the moistening was also useful as helping to ensure the dressing from subsequent displacement. It was early recognised that the drier the dressing the better, and hence anything like a mackintosh layer was carefully avoided. In some instances, antiseptic powders were employed, but they did not find much favour, and because they tended to favour slipping of the dressing, and to prevent the adhesion of the gauze dressing to the wound, they were certainly not desirable when there was any necessity for the patient to travel. In the absence of reliable water the use of antiseptic lotions was obligatory, and such is likely to be the case in most campaigns; in the present one, filtration of the thick muddy water was impossible, without a considerable expenditure of time, which could only be obtained when the hospitals were fairly stationary. I very much preferred carbolic acid lotions. The wound having been once cleansed, or rather the surroundings of the wound, the drier the surface was kept the better; hence a too heavy or impervious dressing was not satisfactory; in point of fact, I think some of the slighter wounds in which all the dressings slipped off, and in which there was less consequent chance of the dressing being moistened with the sweat of the patient, did as well as any. I do not think the bicyanide gauze, absorbent wool, and common open-wove bandages, together with a good supply of nail brushes, soap, and carbolic acid for the primary disinfection of the skin and the external wound, are to be greatly bettered at the present day as materials for the first permanent dressing of cases in the field. The wound itself should be carefully shielded during the preliminary cleansing of the skin by a firmly applied antiseptic pad, and then the dressing applied as above described. The one desirable improvement is some mode of ensuring the dressing being kept in good position, and for this some form of adhesive covering for the gauze and wool should be devised. When the atmosphere is such as to allow of rapid drying, thin moistened book-muslin bandages would be preferable to the plain open-wove ones. The one period of danger is that of transport, and when that is over, the dressing in Stationary or Base hospitals should give no trouble. As a rule the wounds themselves need no interference, but in some instances either the exit or entrance wounds may be in undesirable positions for purposes of asepsis, when a large opening may seem safer closed and actually sealed. I saw this method tried in a few cases, but without much success. It is one which might be of much use in Base hospitals if the patients were brought directly into them, but in the Field hospitals, in face of the rush with which the first dressings have to be done, I think it is seldom applicable, and consider the interference with the wound as rather likely to increase the danger of infection than to decrease it. Dressings should not be too frequent; two should suffice for simple wounds with type forms of entry and exit; there is little discharge and usually no bleeding: hence the more the dry scab form of healing can be simulated the better. When a dressing needs changing from fouling of its outer parts, it is preferable to cut round the adherent part of the deep layers and apply some fresh gauze over the central scab rather than to remove it. One point should be kept in mind: the first dressing in the Field hospital seals the fate of the wound as to the chances of primary union, and hence too much care is impossible with it. Operations in the Field hospitals were proportionately not numerous, and they should be kept down in number, as far as possible. At the same time such operations as are necessary are mostly of capital importance, such as the treatment of fractures of the skull, abdominal section, the ligature of arteries, and amputations. Of these only the first and last classes occur with any degree of frequency. In order to be prepared for these a stock of filtered water which has been boiled, and some special sterilised sponges, should be at hand if possible, also some small towels which can be wrung out in antiseptic lotion. If sterilised sponges are not to be had, wool pads wrung out in carbolic lotion must be substituted. Primary amputations bore transport badly. I saw few sent down from the front within a few days of their performance in which the flaps did not slough, or worse consequences ensue. On the other hand, if the first fortnight could be tided over at the front, they did well enough. The head cases on the other hand bore movement fairly well, provided only that asepsis was ensured. Retained bullets are rarely suitable for removal in the rush of the first work of a Field hospital after an engagement. A short delay is of no importance, and ensures their being removed safely if necessary. With regard to the broad question of the advisability of removing them at all, it may be laid down that they should not be interfered with unless some obvious reason exists. Those most commonly calling for removal are as follows: 1. Bullets lying immediately beneath the skin or quite superficially in any region, or those which, although they have produced an exit opening, yet lie within the body. 2. Those which lie at the bottom of an infected track, or cause secondary suppuration. 3. Those causing pressure on important structures, particularly nerves. 4. Those which interfere with the movements of joints when lodged in the bones or soft tissues in close proximity, or those which lie within the articular cavity itself. Bullets sunk in the great body cavities or in positions difficult of access should never be interfered with. Retained bullets sometimes give rise to unexpected surprises; thus in a man with a retained bullet in the pelvis no steps for its removal were taken. During the man's voyage home on a transport he had an attack of retention of urine. As a catheter would not pass, he was placed in a warm bath, and shortly after passed a Mauser bullet per urethram, and thus saved himself a cystotomy. One word may be added as to the treatment of shock when severe. Quiet in the supine position, and the administration of a small amount of stimulant, was usually all that was required. Hypodermic injections of strychnine sulph. grs. 1/30 to 1/10 were useful, and in some severe cases, especially where operations were needed, saline infusions with a small amount of stimulant were made into the veins, either at the elbow, or in amputation cases into one of the large veins exposed. The treatment of hæmorrhage is dealt with in Chapter IV. The after treatment of simple wounds needs little comment, but bearing in mind what has been said as to the definite healing of the internal portion of the tracks, it will be obvious that in parts such as the thigh or calf, care was needed as to not commencing active work at too early a date. On the other hand, a too long period of absolute rest is also to be deprecated. The best results were obtained by careful movement and massage, commenced after the first week or ten days, according to the appearance presented by the external wound, followed by a gradual resumption of active movement. It was a striking fact that some of the patients suffering from such wounds took longer to become apparently well than many of those who had suffered visceral injuries. FOOTNOTES: [9] _Loc. cit._ p. 31. [10] _Loc. cit._ p. 100. [11] _Loc. cit._ pp. 54, 55. [12] _Wounds in War_, p. 83. Longmans & Co. 1897. [13] A First Field Dressing, _Brit. Med. Jour._ 1900, vol. ii. p. 668. CHAPTER IV INJURIES TO THE BLOOD VESSELS The small calibre of the modern bullet, and its tendency to take a direct course, naturally favour the occurrence of more or less uncomplicated wounds of the large vascular trunks, and both the nature of these wounds and the results which follow them are in some respects most characteristic. NATURE OF THE LESIONS 1. _Contusion or laceration without perforation._--(_a_)The vessel may be struck laterally, the injured portion then forming a part of the bounding wall of the wound track, or (_b_) one or more layers of the vessel wall may be destroyed over a limited area. Given primary union, these conditions are only of importance in so far as subsequent contraction of the lumen of the vessel may result from implication in the neighbouring cicatrix. One of the most striking features of the wounds as a whole was seen in the hair-breadth escapes of the large limb vessels with no subsequent ill effects, and such injuries were seen in every situation. In a certain proportion of wounds in close proximity to large vessels, however, a diminution of the normal calibre of the arteries was observed, either shortly after the injury or later in the advanced stages of cicatrisation. As an example of early obstruction, the following may be related. A Mauser bullet passed from the inner side of the thigh across the neck and great trochanter of the femur beneath the femoral vessels, and probably struck and grooved the bone, since the aperture of exit was large and irregular, some 3/4 of an inch in diameter. One week later no pulse was palpable in either anterior or posterior tibial arteries at the ankle, and pulsation which was strong in the common femoral artery was very weak in the superficial femoral. Slight fulness existed in the hollow of Scarpa's triangle, but not sufficient to make any serious difference in the contour of the two limbs. No thrill or abnormal murmur was discoverable. There was no oedema of the limb, which was also normal in temperature. The patient was kept at rest in the supine position for three weeks, during which time the tibial pulses gradually returned. Three weeks later he was invalided home, the pulses, however, still remaining considerably smaller than normal. In the advanced stages of cicatrisation narrowing of the lumen of the trunk vessels was far from uncommon, especially in cases of wounds of the arm crossing the course of the brachial artery; in many of these the radial pulse was diminished almost to imperceptibility. How far this condition may prove permanent there has been little opportunity of judging; nor as to the possible ultimate weakening of the vessel wall and the development of a secondary aneurism has time allowed the acquisition of experience. In the light of the observation of so many cases in which large vessels were wounded without the occurrence of severe hæmorrhage, either primary or secondary, it is impossible to be certain whether some of the cases of arterial obstruction were not secondary to perforating lesions of the vessels. Pressure on, or minor lesion of the vessel was sometimes evidenced by the development of a murmur, as in the following case. A Mauser bullet entered immediately within and below the left coracoid process, and emerged at the back of the arm at its inner margin, 2-1/2 inches above the junction of the right posterior axillary fold. During the first week dysphagia and some pain and soreness in the episternal notch, with pain and difficulty of respiration, were noticed. Eight weeks later no trouble with the pharynx or oesophagus remained, but a short sharp systolic murmur was audible over the first part of the left axillary artery, which could be extinguished by pressure on the subclavian; the radial pulse was normal.[14] When primary union failed or was prevented by infection and suppuration, lesions, although incomplete, of the vessel coat naturally frequently gave rise to secondary hæmorrhage. 2. _Perforation of the vessels._--(_a_) This may be oblique or transverse to the long axis of a trunk; when the vessel is impinged upon laterally, an oval or circular notch, as the case may be, is produced; or (_b_) the bullet may strike more or less in the centre of the vessel, perforating both in front and behind, while lateral continuity is maintained; (_c_) beyond these degrees a vessel may, of course, be completely divided. Cases of notching of the vessel will be referred to under the heading of traumatic aneurism; those of perforation under that of aneurismal varix and varicose aneurism, the perforations in these cases affecting a parallel artery and vein. RESULTS OF INJURY TO THE VESSELS 1. _Hæmorrhage._--The fact that hæmorrhage was not a prominent feature in the wounds received during this campaign can scarcely be regarded as an experience confined to injuries caused by bullets of small calibre. The same observation was often made in the case of larger bullets in old days, and the absence of severe hæmorrhage has previously been regarded as a special characteristic of gunshot wounds. None the less, as high a proportion as 50 per cent. of deaths occurring on the field in earlier days has been ascribed to this cause. Unfortunately no new facts can be furnished on this point, although a few cases of rapid death from primary hæmorrhage will be found recounted under the heading of visceral injuries. Beyond these the general evidence offered by observations on men brought in from the field with vascular injuries, was opposed to the frequent occurrence of death from hæmorrhage, at any rate of an external nature. This subject will be dealt with under the classical three headings of primary, recurrent, and secondary hæmorrhage. _Primary hæmorrhage._--A marked distinction needs to be drawn between external and internal hæmorrhage. External hæmorrhage from the great vessels of the limbs, or even of the neck, proved responsible for a remarkably small proportion of the deaths on the battlefield. This statement may be made with confidence, since it is not only my own experience, but coincides with what I was able to glean from many medical officers with the Field bearer companies. It is, moreover, supported by the facts that cases in which primary ligature had been resorted to were extremely rare at the Base hospitals, while, on the other hand, traumatic aneurisms and aneurismal varices of any one of the great trunks of the neck and limbs were comparatively common. Again, primary amputation for small-calibre bullet wounds, except when complicated by severe injury to the bones, was so rare as to render more than doubtful the frequent occurrence of severe primary hæmorrhage on the field. Only one case of rapid death due to bleeding from a limb artery was recounted to me. In this a wound of the first part of the axillary artery proved fatal in the twenty minutes occupied by the removal of the patient to the dressing station. The amount of hæmorrhage in many instances was no doubt checked by the application of pressure at the time of the first field dressing; but it can scarcely be argued that such dressings as were applied were of sufficient firmness to control bleeding from such trunks as the brachial, femoral, or carotid arteries. The spontaneous cessation of hæmorrhage is rather to be ascribed to the special method of production and the consequent nature of the wound. The lesions were the result of immense force strictly localised in its application, which might well induce very complete and rapid contraction of the vessel wall; while the track in the soft parts was not only narrow, but also lined by a thin layer of tissue possibly so devitalised superficially as to specially favour rapid coagulation of the blood. Beyond this the tracks were often sinuous when the position of the limb at the time of reception of the injury was replaced by one of rest. The influence of mere narrowness of the track is illustrated by classical experience in the development of aneurismal varices after stabs by knives or bayonets; and in the injuries under consideration the frequent development of large interstitial hæmorrhages into the tissues of the limbs indicated that blood does not readily travel along the wound track. It was noteworthy that when hæmorrhage did occur it was most free from, or often limited to, the wound of exit. This is due to the direction of the active current set up by the rush of the bullet through the tissues. The mechanical factor is, no doubt, the most important. Control of primary hæmorrhage from a wounded vessel by the impaction of a foreign body was of much less frequent occurrence than appears to have been the case with the older bullets. I saw a case in which, on removal of a fragment of shell (Mr. S. W. F. Richardson), very free hæmorrhage occurred from a wound of one of the circumflex arteries of the thigh, but not a single one in which a similar result followed the extraction of a bullet of small calibre. The comparative infrequency of retention of modern bullets is probably one of the main elements in this relation. A very curious instance of provisional plugging of a wound in the upper part of the brachial artery by an inserted loop of the musculo-spiral nerve was related to me by Mr. Clinton Dent. This instance must, I think, be regarded as an accident definitely dependent on the size and outline of the bullet and on the nature of the force transmitted by it to neighbouring structures. While, however, deaths from external primary hæmorrhage were rare, a considerable number resulted from primary internal hæmorrhage. In some of these, injury to the largest trunks in the thorax or abdomen led to an immediately fatal issue; in others wounds of the large visceral arteries, as of the lungs, liver, or mesentery, were scarcely less rapid in their results. In such cases the potential space offered by the peritoneal or pleural cavities favours the ready escape of blood from the wounded vessel, while the tendency of the blood effused into serous cavities to rapid coagulation is notably slight. Beyond this the comparative deficiency in direct support afforded by surrounding structures to vessels running in the large body cavities is also an important element in their behaviour when wounded. These remarks receive support from the observation that few, if any, patients survived an injury to the external iliac vessels within the abdomen, while the remarkable instances of escape from fatal hæmorrhage from large vessels recorded below (cases 1-19) indicate that the mere size of a wounded vessel is not to be regarded as the sole factor in prognosis. _Recurrent hæmorrhage_ was occasionally met with both in the case of the limb and trunk vessels. In the limbs it often necessitated ligature of the artery. I saw several cases in the lower extremity where recurrent hæmorrhage on the second or third day was treated by ligature of the femoral or popliteal artery, and it also occurred during the course of development of one of the carotid aneurisms recounted below. On two occasions I saw rapid death follow recurrent abdominal hæmorrhage; in one I was standing in a tent when a man who had been wounded the day before suddenly exclaimed: 'Why, I am going to die after all.' The appearance of the man was ghastly, and on examining the abdomen it was found greatly distended, and with dulness in the flanks; the patient expired a few minutes later. Another example of recurrent abdominal hæmorrhage is related in case 169, p. 432. _Secondary hæmorrhage._--In simple wounds of the soft parts by _small-calibre bullets_ this was decidedly rare. In wounds complicated by fractures of the bones, especially when they exhibited the so-called 'explosive' character, secondary hæmorrhage was not uncommon, and this not necessarily in conjunction with infection and suppuration. In the chapter on fracture some remarks will be found on the prolongation of healing often observed in the exit portion of the wound track, which is explained by the well-known fact that, given an aseptic condition of the wound, sloughs of tissue separate very slowly. Secondary hæmorrhage in these cases is due to lesions of the vessel short of perforation, but severe enough to so lower the vitality that local gangrene of the wall occurs. In such instances hæmorrhage most usually occurred on the tenth to the fourteenth day, but occasionally still later. In one instance of ligature of the anterior tibial artery for such hæmorrhage three-quarters of the whole lumen of the vessel had been devitalised. The resemblance of some cases of secondary hæmorrhage of this class to those occasionally observed after amputation, and due to accidental non-perforative injury of the artery at the time of operation above the point of ligature, was very striking. In other cases secondary hæmorrhage was the result of perforation of the vessel by a sharp spicule of bone, but in the large majority sepsis and suppuration were the cause. Naturally therefore the accident was commoner in the more severe kinds of wound, and in those caused by _large_ bullets or fragments of shell. The symptoms in nearly all cases were the classical ones of repeated small hæmorrhages followed by a sudden copious gush. The forms of secondary hæmorrhage, however, which afforded most interest were the interstitial and the internal, mainly on account of the scope they allowed for diagnosis. Characteristic examples of internal secondary hæmorrhage are furnished by cases of chest injury accompanied by hæmothorax and fully dealt with under that heading (Chapter X.). Cases of interstitial secondary hæmorrhage are also described under the heading of traumatic aneurism and abdominal injuries (No. 194, p. 445). It therefore suffices here merely to remark on the diagnostic difficulties the condition gave rise to. These mainly depended upon the elevation of general bodily temperature by which the hæmorrhage was often accompanied. Further evidence of the condition was furnished by the development of local swellings, or physical signs indicative of the collection of fluid in a serous cavity. These signs developed rapidly, and the rise of temperature was sudden and decided enough to suggest commencing suppuration. In several cases incisions were made under the supposition that this had already occurred. The fever accompanying blood effusions was generally a somewhat special feature in the wounds of the campaign. At first bearing in mind that in every case a track, even if closed, led from the surface to the effused blood, one was disposed to suspect an infection of the clot of a somewhat innocuous nature. The absence of subsequent suppuration, however, was definitely opposed to this view, and suggested that the fever resulted from absorption of some element of the blood, possibly the fibrin ferment, or some form of albumose. A pronounced illustration was in fact afforded of the evanescent rise of temperature usually the accompaniment of simple fractures in the case of the limbs, and of the more marked rise not uncommon in cases of traumatic blood effusion into the peritoneal cavity, or when the pleuræ or joints were the seats of the mischief. In the case of interstitial hæmorrhages I only remember to have seen fever of such marked continued type in the subjects of hæmophilia with recent effusions, although one is of course acquainted with it in a less pronounced form as a result of hæmorrhage into operation wounds. In primary interstitial hæmorrhages a similar continued rise of temperature was also common, and I cannot perhaps better illustrate its character than by the brief relation of two instances. In a patient wounded at Kamelfontein the bullet entered four inches below the acromion, pierced the deltoid, splintered the humerus, and crossed the axilla. A large blood extravasation developed in the axilla, accompanied by cutaneous ecchymosis extending halfway down the arm. There was no perceptible pulsation in either the brachial or radial artery, but the limb was warm. There was partial paralysis of the parts supplied by the ulnar and musculo-spiral nerves and complete loss of power and sensation in the area of distribution of the median nerve. Six months later the radial pulse was still absent in this patient, but there was no sign of the development of an aneurism. [Illustration: TEMPERATURE CHART 1.--Axillary Hæmatoma. Shows range of temperature during process of absorption and consolidation without suppuration] The accompanying temperature chart is characteristic. The blood effusion gradually gained in consistency and underwent steady diminution in size. No suppuration occurred. The median paralysis was found to be accompanied by the inclusion of the nerve in a sort of foramen of callus, when the patient was explored at a later date by Mr. Ballance. In a patient wounded at Paardeberg, a Mauser bullet entered by the left buttock, pierced the venter ilii, traversed the pelvis, and emerging at the brim of the latter, crossed the back, fractured the spine of the fourth lumbar vertebra, and escaped below the twelfth right rib. The track suppurated where it crossed the back, but the man did well until the twentieth day, when a swelling developed in the left iliac fossa and the general temperature rose to 102°. An abscess was at once suspected and the swelling incised by Major Lougheed, R.A.M.C. A large subperitoneal hæmatoma only was discovered, and evacuated. The temperature at once fell and the after progress was uneventful, the wound healing by primary union. TREATMENT OF HÆMORRHAGE _Primary._--No deviation from the ordinary rules of surgery should be necessary in the majority of cases, but in a certain number the conditions are so unusual that the special considerations must be taken into account. The natural tendency to spontaneous cessation of primary hæmorrhage in small-calibre wounds is the first of these. Experience has shown that often mere dressing, or at any rate slight pressure, suffices to efficiently stanch immediate bleeding. Although, however, immediate control is to be obtained by such means, the cases of traumatic aneurism of every variety related in the next section show that the ultimate result is in many such cases by no means satisfactory. Under these circumstances it may be said that the classical rule of ligation at the point of injury should never be disregarded. Against this, however, certain objections may be at once raised; thus in many cases both artery and vein need ligature, a consideration of much importance in the case of such vessels as the carotid and femoral arteries. Again in many of the injuries to the popliteal artery the wound directly communicated with the knee joint, a complication which, while it may be disregarded in civil practice, must take a much more important place in the circumstances under which many operations in military surgery are performed. On the whole, it seems clear that the military surgeon must be guided by circumstances, since it may be far better to risk the chances of recurrent hæmorrhage, or the development of an aneurism or varix, all of which are amenable to successful treatment later, than those of gangrene of a limb or softening of the brain. As a general rule, therefore, on the field or in a Field hospital, primary ligature of the great vessels is best reserved for those cases only in which hæmorrhage persists, while in those in which spontaneous cessation has occurred, or in which bleeding is readily controlled by pressure, rest and an expectant attitude are to be preferred. A word must be added as to the objections to distant proximal ligature for primary or recurrent hæmorrhage. In some situations this may be unavoidable, and it is sometimes successful, but none the less it is opposed to all rules of good surgery and a most uncertain procedure. It leaves the patient exposed to all the risks attendant on the employment of simple pressure. In one case which I saw, the third part of the subclavian artery had been ligatured for axillary bleeding; secondary hæmorrhage, as might have been expected, occurred, and that as late as five weeks after the operation. In another case ligature of the femoral artery for popliteal hæmorrhage was followed by the development of a traumatic aneurism in the ham. _Secondary._--In secondary hæmorrhage the treatment to be adopted depends upon the nature of the case. When the wound is aseptic, and bleeding the result of the separation of sloughs, local ligature is the proper treatment, and this was often successfully adopted, especially in the case of such arteries as the tibials. In septic cases, on the other hand, it is usually far better if possible to amputate, unless the general state of the patient and the local conditions are especially favourable. When neither amputation nor direct local ligature is practicable, proximal ligature may be of use. Sometimes this may be obligatory in consequence of the difficulties attendant on direct local treatment. I saw a few cases successfully treated in this manner: in one the common carotid was tied (Mr. Jameson) for hæmorrhage from an arterial hæmatoma in connection with the internal maxillary artery. Although ligature of the external carotid would perhaps have been preferable, the result was excellent. When even this expedient is impracticable, local pressure is the only resort. Lastly, as to the treatment of secondary interstitial blood effusions, I believe the best initial treatment is the expectant. If interference is needed, it is much more likely to be satisfactory the more chronic the condition has become, since the source of the bleeding may be impossible to discover. I never saw a patient's life endangered by the amount of such hæmorrhage, but if this should seem to be likely, local treatment is of course unavoidable. In several cases quoted below, incision and evacuation were followed by excellent results; in any such operation too much care to ensure asepsis is impossible. TRAUMATIC ANEURISMS The experience of the campaign fully bears out that of the past as to the steady increase of the number of aneurisms from gunshot wounds in direct ratio to diminution in the size of the projectiles employed. Every variety of traumatic aneurism was met with, and most frequently of all, perhaps, aneurismal varices and varicose aneurisms. While so experienced a military surgeon as Pirogoff could say, in 1864, that he had never seen a case of aneurismal varix, every young surgeon lately in South Africa has met with a series. Again, although the condition is a well-known one, it has been rather in connection with civil life; for the great majority of recorded cases were the result of stabs or punctured wounds such as are liable to be received in street brawls, or as a result of accidents with the tools of mechanics. Thus of ninety cases collected by K. Bardeleben in 1871, only 12 or 13.33 per cent. were the result of gunshot wound. _False traumatic aneurism or arterial hæmatoma._--This condition was met with comparatively frequently, and bears a very close relation to that already described under the heading of interstitial hæmorrhages. The latter might almost have been included here, since the difference between the two conditions depended merely on the size of the vessels implicated. The exact correspondence in the period of development of some of the arterial hæmatomata, and of the occurrence of the aseptic form of secondary hæmorrhage, also explains the pathology of the two conditions as identical; except that in the former the effused blood is retained in the tissues, while in the latter it escapes externally. The history of these cases was uniform and characteristic. A wound of the soft parts, or sometimes a fracture, was accompanied by a certain degree of primary interstitial hæmorrhage, which might or might not have been associated with external bleeding. A hæmatoma resulted in connection with the wounded vessel, the general tendency in the effusion being to coagulation at the margins and subsequent contraction. Meanwhile the opening in the artery became more or less securely closed by the development of thrombus, and possibly by retraction of the inner and middle coats of the vessel. With the return of full circulatory force as shock passed off, or with the resumption of activity and consequent freer movement of the limb, the temporary thrombus became washed away. The newly formed wall of soft clot bounding the effusion proved insufficient to withstand the full force of the blood pressure, and extension of the cavity resulted. In the more rapidly developing hæmatomata, temporary pressure by the effused blood on the bleeding vessels was also, no doubt, a common explanation of temporary cessation of increase in size. A diffuse soft fluctuating swelling, sometimes accompanied by pulsation, but oftener without, developed, and not uncommonly diffusion was accompanied by some discoloration of the surface and elevation of the general temperature. Such arterial hæmatomata commonly developed from ten days to three weeks after the original wound. A few examples will suffice. (1) A patient wounded at Elandslaagte was sent down to Wynberg. The antero-posterior wound in the upper third of the arm was healed, but a month after the injury a large fluctuating arterial hæmatoma developed in the axilla and upper third of the arm. This was incised (Colonel Stevenson) and a wound of the axillary artery in its third part discovered, and the vessel ligatured. The patient made an excellent recovery. (2) A patient received a wound at Doornkop which traversed the calf in an obliquely antero-posterior longitudinal direction. Three weeks later a soft fluctuating swelling developed at the inner margin of the tendo Achillis occupying the lower third of the leg. Neither pulsation nor murmur was detected. There was anæsthesia in the area of distribution of the posterior tibial nerve. No tendency to further increase was observed, and operation was postponed. The temperature was normal. (3) An Imperial Yeoman was struck at Zwartskopfontein at a range of one hundred yards. The man rode four miles on his horse after being hit, but the horse then fell and rolled over him twice. The man was treated successively in the Van Alen, Boshof, and Kimberley Hospitals, and from the last he was sent to Wynberg which place he reached on the twenty-third day. When admitted into No. 2 General Hospital the wounds of type form and size (_entry_, in posterior fold of axilla; _exit_, 1-1/2 inch below junction of anterior fold with arm) were healed. The whole upper arm was swollen and discoloured, while an indurated mass extended along the line of the vessels into the axilla. This was considered a blood effusion; it was not obviously distensile, and pulsation was very slight. The brachial radial and ulnar pulses were absent. A fluctuating swelling was present along the anterior border of the deltoid. There were some signs of nerve contusion, but no paralysis, beyond tactile anæsthesia in the area of distribution of the median nerve. Four days later little alteration had been noticed beyond a tendency to variation in firmness of the different parts of the swelling. On the thirty-first day considerable enlargement was observed. This enlargement, together with continued rise of temperature, aroused the suspicion of suppuration, and an exploratory puncture with a von Graefe's knife was made by Major Lougheed, R.A.M.C., after consultation with Professor Chiene. Blood clot first escaped, followed by free arterial hæmorrhage. The incision was enlarged while compression of the third part of the subclavian was maintained; a large quantity of clot was turned out, and an obliquely oval wound half an inch in long diameter was found in the axillary artery. Ligatures were applied above and below the opening between the converging heads of the median nerve. The veins were not damaged. The wound healed by first intention. On the twelfth day a feeble radial pulse was perceptible, and shortly afterwards the man left for England, diminished median tactile sensation being the only remnant of the original symptoms. (4) A private of the 2nd Rifle Brigade was struck while doubling at Geluk, at a range of one hundred yards. The Mauser bullet entered four inches above the upper border of the left patella, internal to the mid line of the limb, and escaped in the centre of the popliteal space. The man lay in a farmhouse during the night and bled considerably from both wounds. He did not fall when struck, but could not walk. He was sent to No. 2 General Hospital in Pretoria. On arrival there the external wounds were scabbed over, and a large tumour existed beneath the entrance wound. There was much discoloration from ecchymosis, but no pulsation could be detected. The posterior tibial pulse was good. At the end of ten days pulsation became marked both in the front of the limb and in the popliteal space. There were no symptoms of nerve injury. On the thirteenth day an Esmarch's bandage was applied and Major Lougheed laid the tumour open opposite the opening in the adductor magnus. Much clot was removed, and both artery and vein, which were found divided in the adductor canal, were ligatured. The foot remained very cold for the first twenty-four hours, but otherwise progress was satisfactory, the wound healing by first intention. No pulsation was palpable in the tibials at the end of a month. For the last two cases I am very much indebted to Major Lougheed. I am glad to include them, as they illustrate one or two points of special importance. No. 3 shows the tendency to variation in the tension and firmness of the tumours, the tendency to primary contraction of the sac, followed by diffusion, and the rise of temperature often accompanying the latter occurrence. This is of great interest in relation to the similar rise of temperature seen with the increase of hæmorrhage in cases of hæmothorax. For purposes of comparison, the progress may well be considered alongside of that in the case related on p. 119, in which the wounded vessel was probably also the main trunk itself. No. 4 differs from any of the others in depending on a complete division of a large artery and vein. The development of the hæmatoma was consequently more rapid and continuous. Another point of interest was the maintenance of pulsation in the tibial vessels, in spite of complete solution of continuity in the parent trunk. That this was independent of the collateral circulation seems evident from its complete disappearance and slowness of return after ligation of the wounded vessels. _Prognosis and treatment._--The treatment in these cases is sufficiently obvious, and consists in direct incision and ligature of the wounded vessels. The cases related show the success with which this procedure was attended, since uniformly good results were obtained. When possible, an Esmarch's tourniquet should be applied in the case of the lower limb. In the upper, compression of the subclavian is necessary during interference with axillary hæmatomata, combined with direct pressure on the bleeding spot after the clot has been removed. In the case of the arm, digital compression is always to be preferred, in view of the well-known danger of damage to the brachial nerves from the tourniquet. Proximal ligature is always to be avoided. It is inadequate, and proved more dangerous as far as the vitality of the limb was concerned, the latter point probably depending on the interference with the collateral circulation by pressure from the extravasated blood, which is unrelieved by the operation. I know of at least two cases of gangrene which occurred consecutively to proximal ligature of the femoral artery for this condition. _True traumatic aneurisms._--The cases met with differed so little from those seen in ordinary civil practice, that but slight notice of them is necessary. They differed from the last variety mainly in the more localised nature of the tumour, the greater firmness of its walls, and the more pronounced expansile pulsation. The development of this form of aneurism was probably influenced by several circumstances, such as the more complete rest secured for the patient, the locality in the limb as affecting movement of the spot in the vessel actually wounded, the size of the opening in the vessel, and the degree of support afforded by surrounding structures. (Examples are furnished by cases 6-9.) Under the influence of rest, all that I saw tended to contract and become firmer, and they so far resembled spontaneous aneurisms as to be readily cured by proximal ligature of the artery. The ideal treatment no doubt consists in local incision and ligature on either side of the wounded spot, with or without ablation of the sac. The choice of direct or proximal ligature in any case depends on the position of the aneurism, and the ease with which the former operation can be carried out. In all these cases a very great advantage in the localisation and diminution of the tumours was gained by postponing interference until they became stationary. I need scarcely add that any evidence of diffusion indicated immediate operation. The preference of direct or proximal ligation will probably, to a certain extent, always depend on the personal predilection of the surgeon, but while proximal ligature has often given good immediate results during this campaign, it cannot be with certainty decided whether the patients are definitely protected from the dangers of recurrence. Reference to cases 7 and 9 as illustrating the possible spontaneous cure of traumatic aneurisms is of great interest. I saw a number of cases successfully treated by proximal ligature; also a number where continuous improvement followed rest, and which were sent home for further treatment. None of these demand any special mention. One case of a very special nature, which terminated fatally, is of great interest:-- (5) In a man wounded at Belmont the bullet entered the second left intercostal space and was retained in the thorax. He was sent directly to the Base and came under the care of Mr. Thornton at No. 1 General Hospital, Wynberg. Signs of wound of the lung developed in the form of hæmoptysis and left hæmothorax. The left radial pulse was almost imperceptible. The entry wound did not close by primary union, and three weeks later an incision was made into the chest in consequence of the presence of fever, progressive emaciation, and weakness. Breaking down blood clot was evacuated: general improvement followed, and the radial pulse increased considerably in volume. A fortnight later sudden severe hæmorrhage occurred from the external wound, and the man rapidly collapsed and died. At the post-mortem a traumatic aneurism the size of an orange was found in connection with an oval wound in the first portion of the left subclavian artery which admitted the tip of the forefinger. This case is noteworthy as an illustration of the magnitude of an artery which can be wounded without leading to rapid death from primary hæmorrhage, even when in communication with a serous sac, and still more as emphasising the importance of weakening of the radial pulse as a sign in connection with a wound of the upper part of the chest on the left side. It is somewhat surprising that this sign was not marked in two cases (Nos. 13 and 14, p. 140) recorded below, in which the innominate and right carotid arteries respectively were probably perforated. (6) _Traumatic popliteal aneurism._--Wounded at Modder River. _Entry_ (Mauser), over centre of tibia 1 inch above the tubercle. _Exit_, about centre of popliteal space. No hæmorrhage of any importance occurred from the wound, but there was a typical hæmarthrosis, which subsided slowly. Twelve days after the injury a pulsating swelling the size of a hen's egg, to which attention was drawn on account of pain, was noted in popliteal space. The pulsation extended upwards in the line of the artery some 3 inches. The limb was placed on a splint and treated by rest, and a month later the aneurism had decreased to one half its former size, the wall having greatly increased in firmness. Pulsation was easily controlled by pressure above the tumour; there was no thrill present, but a high-pitched bellows murmur. The patient was sent home on February 1. When admitted at Netley the patient came under the care of Major Dick, R.A.M.C., who ligatured the popliteal artery on the proximal side by an incision in the line of the tendon of the adductor magnus. The aneurism then consolidated. (7) _Traumatic popliteal aneurism._--Wounded at Magersfontein. _Entry_ (Mauser), centre of patella. _Exit_, centre of popliteal space; the knee was bent at the time it was struck. There was considerable primary external hæmorrhage, and so much blood collected in the knee-joint that it was aspirated. On the eighth day secondary hæmorrhage occurred from the exit wound and the femoral artery was tied in Hunter's canal. No further hæmorrhage occurred, but at the end of three weeks feeble pulsation was palpable in the popliteal space, suggesting an aneurism; the latter decreased and the patient was sent home apparently well. (8) _Traumatic axillary aneurism._--Wounded at Karree. The bullet entered 2-1/2 inches below the acromial end of the right clavicle and emerged over the 9th rib in the posterior axillary line. The Mauser bullet was found in the patient's haversack. Both apertures were of the slit form, and healed per primam. Three weeks later at Wynberg a large arterial hæmatoma which pulsated was noted in the axilla. Signs of injury to the musculo-spiral nerve were also observed. The tumour altered little, but a fortnight later Major Burton, R.A.M.C., cut down upon it through the pectorals. The aneurism was of the third part of the axillary artery, and a ligature was applied at the lower margin of the pectoralis minor. The wound healed by primary union and the aneurism rapidly shrank. The patient left for England a month later; the musculo-spiral paralysis was improving. I am indebted to Major Burton for the notes of this case. (9) _Traumatic popliteal aneurism._--Wounded in Natal. _Entry_ (Mauser), immediately above head of fibula. _Exit_, immediately inside semi-tendinosus tendon at level of central popliteal crease. Fulness but no pulsation was noted at end of three weeks; seven days later pulsation was evident, and an aneurism the size of a pigeon's egg, with firm walls, became localised and palpable. It gave rise to no symptoms, and patient refused operation during the three weeks he remained in hospital. The aneurism continued to contract, and the patient was sent home. The aneurism has since spontaneously consolidated. _Aneurismal varix and varicose (arterio-venous) aneurism._--Uncomplicated cases of aneurismal varix, as might be expected, were less common than those in which the arterio-venous communication was accompanied by the formation of a traumatic sac. The initial lesion accountable for each condition was, however, probably identical, and dependent on the passage of a bullet of small calibre across the line of large parallel arteries and veins. Thus, obliquely coursing antero-posterior wounds of the neck produced carotid and jugular varices; vertically coursing tracks laid the subclavian vessels in communication; antero-posterior tracks the brachial, popliteal, and lower part of the femoral; and transverse tracks, the vessels of the calf and forearm. Given an arterial wound, the mode of development of the aneurismal sac in no way differs from that of the ordinary traumatic variety; the main point of interest, therefore, is to seek an explanation of the causes which may restrict the ultimate result to the formation of a pure aneurismal varix. The explanation is possibly to be found in some of the following circumstances. _Size, position, and symmetry of the vascular wound._--It seems scarcely necessary to insist on the calibre of the projectile, since this alone determined the frequency of these conditions, but it must be borne in mind that in the diameter of the bullets, classed as of small calibre during this war, a range of from 6.5-8 mm. existed. In the case of both the Krag-Jörgensen and Mauser, the shape of the bullet also was better adapted to pure perforation of the vessels. I saw no case of arterio-venous communication in which a larger bullet than one of the four types chosen had been responsible for the primary injury, but a difference of 1-1/2 mm. in calibre in the small projectile might well determine the division, the pure and symmetrical perforation of the two vessels, or the giving way of one side, so that they were deeply notched instead of perforated. Such positive evidence as was afforded by operation as to the exact condition of the vessels in two cases of femoral arterio-venous aneurism was, that in either case a clean perforation existed. It is improbable that notching of the two vessels can primarily produce a pure varix, although it may result in the formation of an arterio-venous aneurism, especially if the bullet should have passed between the two vessels in such a way as to notch the contiguous sides. It is impossible to say, in any given case, what the result of secondary contraction of a sac produced in this manner may be in the determination of the ultimate relation of the vessels. In many of the cases clinically designated pure varix, the remains of such a sac may still actually persist. In the case also of pure perforation of the vessels, it is difficult to believe that a localised blood cavity has not originally existed. Given complete division of the vessels, as far as my experience went, arterial hæmatoma was the uniform result. Under these circumstances I am inclined to believe that a symmetrical perforation of both vessels is the most common precursor of either condition; that the pure varix is the rarer and less likely result, and that its formation is dependent mainly on certain anatomical conditions. The most important of these conditions are the proximity and degree of cohesion of the two vessels, the comparative spaciousness or the opposite of the vascular cleft, and the degree of support afforded by surrounding structures. Thus, the close proximity of the popliteal artery and vein, together with the particularly firm adhesion which exists between the vessels, probably favours the formation of a varix; again, a varix more readily forms if the femoral artery and vein are wounded in Hunter's canal than if the injury is situated high in Scarpa's triangle, where the vessels lie in a large areolar space. The passage of a bullet between an artery and vein may perhaps produce either condition, but wide separation of the two vessels, as for instance of the subclavian artery and vein, renders an aneurismal sac almost a certainty. These suggestions seem borne out by the cases recounted below, since the pure varices are one femoral, one popliteal, and one axillary. I cannot include the calf and forearm cases, as the existence of a small sac could not be disproved. To these anatomical factors certain others must be added. In most cases a false sac exists at first, which tends to undergo contraction and spontaneous cure, as is observed in some of the ordinary traumatic sacs. This history of development is moreover supported by the observation that proximal ligature of the artery usually converts an arterio-venous aneurism into an aneurismal varix. The process is no doubt favoured by cleanness and small size of the perforation, moderation in the amount of primary hæmorrhage, the tone and resistance of the surrounding tissues, special points in the circulatory force and condition of the blood, and the possibility of maintaining the part at rest after the injury. Aneurismal varix, when pure, was evidenced by the presence of purring thrill and machinery murmur alone. In none of the cases I saw was pain or swelling of the limb present. In one popliteal varix, slight varicosity of the superficial veins of the leg was present, but it was not certain that the development of this was not antecedent to the injury, as the patient did not notice it until his attention was drawn to its existence. In none of the cases under observation in South Africa had enough time elapsed for sufficient dilatation of the artery above the point of communication to give rise to any confusion from this cause as to the presence of a sac. When an arterio-venous sac has once formed, clinical observation shows that the general tendency is towards extension in the direction of least resistance. This direction of course varies with the situation of the aneurism, and also with the nature of the wound track. Speaking generally the direction of least resistance in a typically pure perforation is towards the vein. Initial flow of blood from the wounded artery is naturally favoured towards the potential space afforded by a canal occupied by blood flowing at a lower degree of pressure. The partial collapse of the vein dependent on the wound in its wall also probably helps in determining the initial flow in its direction. Examples are afforded by the carotid aneurisms (cases 10, 11, and 14), and here it must be borne in mind that the outer limits of the cervical vascular cleft are those least likely to offer resistance to extension of the sac. In each the aneurisms mainly occupied the exit segment of the track; this is the general rule, as in the case of external hæmorrhage, and is determined by the same cause. The latter rule however finds exceptions when the entry segment is so situated as to cross a region of lesser resistance, and case 12 illustrates this point with regard to the cervical vascular cleft. Examples of the tendency to spread in the anatomical direction of least resistance are also offered by the cases of aneurism at the root of the neck, where extension was into the posterior triangle. The further clinical history and signs are as follows. A local swelling is found, usually at first diffuse, often commencing to develop with cessation of the external hæmorrhage. It increases, for the first few days maintaining its diffuse character. If near the surface, it may be superficially ecchymosed. At the end of this time a tendency to localisation, as evidenced by increasing firmness and more definite margination, takes place, and this is followed by general contraction and rounding off of the tumour. The latter process may be continuous, and eventually the sac may become small and stationary or ultimately disappear and a pure varix be the result. The latter is only likely to be the case under the most satisfactory of the conditions enumerated above. Occasionally an opposite course may be followed, and fresh extension take place, as evidenced by enlargement of the tumour, disappearance of sharp definition, softening, and pain. The natural termination of such cases in the absence of interference would no doubt be rupture, and possibly death in some positions, loss of the limb in others. The former I never saw. _Purring thrill._--This, the pathognomonic sign of either condition, was always present in the fully developed stage, and is probably present from the first unless a temporary thrombosis obstructs the vascular openings. It was noted as early as the third day in case 13. In many of the other patients it was palpable only with the subsidence of the primary swelling attendant on the injury. In some of the forearm and calf aneurisms, and in some of the popliteal, it was only discovered by accident some weeks even after the injury, but this often because no serious vascular lesion had been suspected. The thrill was widely conducted, often apparently superficial on palpation, and much more pronounced with light than with forcible digital pressure. In case 10 the _visible_ vibration in consonance with the thrill when the vein was exposed during the operation of ligature of the carotid was a novel experience to me. _Murmur._--The typical 'bee in the bag,' or 'machinery' murmur was present in every case, and was often very widely distributed, especially over the thorax. (Cases 13, 14, and 20.) In all three carotid cases the murmur was troublesome, being audible to the patient at night when the head was rested on the side corresponding to the aneurism. _Expansile pulsation._--Pulsation in combination with the existence of a tumour is the main feature in the diagnosis between the conditions of pure varix and varicose aneurism. It was not always existent or prominent in the earliest stages, probably from temporary blocking of the artery, or from the diffuse and irregular nature of the cavity offering conditions unsuitable to the satisfactory transmission of the wave. When localisation had occurred it was always present. EFFECTS OF ANEURISMAL VARIX OR VARICOSE ANEURISM ON THE CIRCULATION (_a_) _General._--The most striking feature in these injuries is the remarkable effect of the disturbance to the even flow of the circulation on the heart. This first struck me in two of the cases of carotid arterio-venous aneurism recorded below (Nos. 10 and 11). In these I was inclined at first to attribute the rapid and irritable character of the pulse solely to injury to the vagus, as in each laryngeal paralysis pointed to concussion or contusion of the nerve. The pulse reached a rate of 120-140 to the minute. This disturbance was not of a transitory nature, for in the two cases referred to the rapid pulse persists, in spite of entire recovery of the laryngeal muscles, and the fact that in one case the aneurismal sac has been absolutely cured, and in the second only a small sac remains, in each as a result of proximal ligature of the carotid artery. In the former a varix still exists, and at the end of seven months the pulse is still over 100. In the latter, in which a sac is still present, the pulse rate varies from 110 to 130. In each case the condition has now existed twelve months. My attention once directed to this point, I noted a similar acceleration of the pulse in the case of these aneurisms elsewhere; thus in a femoral aneurism the rate was 120, and in an axillary varix of twenty years' standing which came under my observation the pulse rate varied from 110 to 120, according to the position of the patient. Unfortunately I had not directed my attention to this point in the early series of cases which came under observation. It will be remarked in cases 13 and 14 that at the expiration of a year the pulse rate was still high, but these again are cervical aneurisms each in contact with or near the vagus. In a case of aneurismal varix of the femoral artery of three years' standing, which was under the charge of Mr. Mackellar, the pulse rate was normal. In this instance great dilatation of the vessels had occurred. These observations raise the interesting question whether the irritable circulation which has been classically considered one of the predisposing causes of spontaneous aneurism should not rather be regarded as a result of the condition. (_b_) _Local._--In none of the cases of varix was the period of observation long enough to allow me to determine the development of dilatation of the arterial trunk above the point of obstruction. This, however, is the common sequence, and no doubt will occur in those patients who resume active occupation without operation. The effects of either condition on the distal circulation were remarkably slight. The distal pulses were little, if at all, modified in strength or volume, and signs of venous obstruction, if present at first, disappeared with much rapidity. In one case (No. 15) of a large arterio-venous popliteal aneurism there was considerable swelling of the leg, but in this case the sac was large and situated at the apex of the space, and no doubt exercised external pressure on the vein. In the case of the carotid aneurisms, especially that probably on the internal carotid, transient faintness was a symptom in the early stages of the case. All three of the cases recorded here, however, had been the subjects of very free hæmorrhage, either primary or recurrent. (10) _Carotid arterio-venous aneurism._--Wounded at Paardeberg. _Entry_ (Mauser) to the right side of the Pomum Adami, _exit_ at anterior margin of left trapezius, two inches below the angle of the jaw. There was some hæmorrhage at the time from the exit wound, but no hæmoptysis; about four hours later, however, in the Field hospital bleeding was so free that an incision was made with the object of tying the common carotid. During the preliminary stages of the operation bleeding ceased and the wound was closed without exposing the vessel. The patient remained a week in the Field hospital, and then made a three day and night's journey in a bullock waggon to Modder River (40 miles), and fourteen days later he was transferred to the Base hospital at Wynberg, when the condition was as follows. Operation and bullet wounds healed. Considerable extravasation of blood in the posterior triangle. Beneath the sterno-mastoid in the course of the bullet track, swelling, thrill and pulsation over an area 1-1/2 inch wide in diameter. Loud machinery murmur audible to the patient when the left side of the head is placed on the pillow, and widely distributed on auscultation. The left eye appears prominent, but the pupils are normal and equal in size. Voice weak and husky, and there is cough. Laryngoscopic examination showed the cords to be untouched, but some swelling still persisted. No headache, but giddiness is troublesome at times. Pulse 100, regular but somewhat irritable. The patient was kept quiet in the supine position for a month, and during this time the condition in many ways improved. The voice improved in strength, the pulse steadied, falling to 80, the prominence of the left eye disappeared, and all the blood effusion in the posterior triangle became absorbed. Meanwhile the aneurism contracted at first, until it became oval in outline, with a long axis of 2 inches by 1-1/2 broad extending in the line of the wound track, but mainly situated in the exit half. During the last fortnight, however, it remained quite stationary in size, and as it showed no further signs of diminution in spite of the favourable conditions under which the patient had been placed, it was considered best to try to ensure its consolidation by a proximal ligature. Thrill had become slightly less pronounced, and was less evident to the patient himself, but was otherwise unchanged. The probabilities in this case seemed rather in favour of wound of the internal carotid artery, and it was decided to bare the upper part of the common carotid, follow up the main trunk, and if possible apply the ligature to the internal branch. On April 12, 61 days after the injury, the classical incision for securing the common carotid was made, and the sterno-mastoid slightly retracted. It was found that the sac of the aneurism extended over the bifurcation of the artery, reaching to the wall of the larynx. The omo-hyoid muscle was therefore divided, and the artery ligatured beneath, in order to ensure against any interference with the sac. Some difficulty was met with, for on opening the vascular cleft the vein was exposed and found to completely overlie the artery: although it was on the left side of the neck, the position of the vein was so completely superficial that there seemed no doubt that it had been displaced by the development of the aneurismal sac. A striking appearance was noted on exposure of the vein, the coats of which vibrated visibly, quivering in exact consonance with the palpable thrill. On tightening the silk ligature all pulsation ceased in the aneurism, and the vibratory thrill in the vein became much lessened. The patient made a good recovery, only disturbed by a slight attack of vomiting, and at the end of a week the wound had healed, and pulsation in the aneurism had completely ceased. The thrill persisted as before. Six months later, a small sac still exists beneath the sterno-mastoid. The pulse still reaches 110-120 in pace. The purring thrill is very slight. The condition gives rise to little or no trouble. Pulsation is strong in the external carotid artery, there is little in the common carotid. The voice is strong and good. This aneurism is either at the bifurcation of the common carotid, or on the immediate commencement of the internal carotid. Ligature of the external carotid will probably cure it. (11) _Arterio-venous aneurism, probably affecting both carotids._ Wounded at Paardeberg. _Entry_ (Mauser), at dimple of chin immediately below mandibular symphysis. _Exit_, at margin of right trapezius, the track crossing the carotids about the level of normal bifurcation. The patient was lying on his back with the head down when struck. Some hæmorrhage from the exit wound occurred at the time, and later on the way to Jacobsdal this was so profuse as to be nearly fatal. A considerable hæmorrhage also occurred on the tenth day. The patient made the journey to Modder River safely, and was then under the charge of Mr. Cheatle. A large diffuse pulsating swelling developed on the right side of the neck, with well-marked thrill and machinery murmur. During the next three weeks the swelling steadily contracted, and the patient was sent down to the Base one month after receiving the wound, when the condition was as follows. There is no evidence of any fracture of the jaw. On the right side of the neck a large aneurism fills the carotid triangle, extending from the mid-line backwards to the margin of the trapezius, and from the level of the top of the larynx upwards to the margin of the mandible. The wall is fairly firm, pulsation is both visible and palpable, and a well-marked thrill and machinery murmur are present. The latter annoys him by its buzzing when the head rests on the right side. The pupils are equal. Pulse somewhat irritable, about 100. The voice is weak and husky, and there is difficulty in swallowing solids. The actual swelling is somewhat remarkable in outline, on the one hand following up the course of the external carotid and facial arteries, and on the other extending backwards in the line of the wound track towards the exit. The patient was kept on his back with sandbags around the head during the next fortnight. For the first eight days such change as occurred was in the direction of localisation and contraction, but during the last six, evident extension occurred both backwards and downwards; this extension was accompanied by severe pain in the cutaneous cervical nerve area of the neck. The larynx became pushed over 3/4 of an inch to the left of the median line, and the extension beneath the sterno-mastoid downwards raised a doubt as to whether the common carotid could be exposed without encroaching on the walls of the sac. Owing to indisposition I had not been able to see the patient for some days, but now, after consultation with Major Simpson and Mr. Watson, it was decided that the best plan would be to expose and tie the common carotid as high as could be safely done. The operation was performed six weeks after the injury, and somewhat to our surprise offered little difficulty. The carotid was exposed at the upper border of the omo-hyoid, only a small amount of infiltration having occurred in the vascular cleft. No dilatation of the jugular was noticeable, and when a silk ligature was applied to the artery all pulsation was controlled, and the thrill in the vein disappeared completely. The after progress was satisfactory, but four days later the wound was dressed, as the patient's temperature had risen above 100°. The tumour was consolidated: no pulsation could be felt, but there was little apparent diminution in its size. A loud blowing murmur was audible, especially at the posterior part of the swelling. On the morning of the fifth day the patient mentioned that he again heard the whirr during the night. There had been no sign of any cerebral disturbance and the pupils had remained equal throughout. A week after the operation the stitches were removed, there was evidence of some blood clot in the lower part of the wound, and this later liquefied and was let out on the eleventh day. At that time a slight bubbling thrill could be felt at the upper part of the tumour, also slight pulsation in the line of the external carotid and at the most posterior part of the sac. The latter was much contracted, diminished in size and apparently solid, so that it was hoped that such pulsation as existed was communicated. Ten months later, no trace of the aneurismal sac exists. Neck normal, except for purring thrill. Voice strong and good. Pulse 100. Following his usual work. (12) _Carotid arterio-venous aneurism_.--Wounded at Paardeberg. Aperture of _entry_ (Mauser), at the posterior border of the left sterno-mastoid, 1 inch above the clavicle; _exit_, near the posterior border of the right sterno-mastoid, 2 inches from the sterno-clavicular joint. The injury was followed by very free hæmorrhage, mainly from the wound of entry, some 'quarts' of blood escaping; at any rate his clothes were saturated. The voice was hoarse and weak, and there was much difficulty in swallowing; for the first twenty-four hours he could swallow nothing, but gradual improvement took place. The patient was carried two miles to the Field hospital, and three days later travelled 36-40 miles in a bullock waggon to Modder River. Thence he travelled to Orange River 55 miles by train on the next day. A swelling was first noted when the wound was dressed some seven days after the injury. No evidence was ever existent of gross damage to either trachea or oesophagus beyond the initial dysphagia. The hoarseness of voice due to left laryngeal paralysis slowly improved, and was probably the effect of concussion or contusion of the left recurrent laryngeal nerve. During the patient's stay at Orange River a large pulsating swelling with a strong thrill developed. This was at first diffuse, but under the influence of rest it steadily contracted and localised. During this period the patient was seen several times by Mr. Cheatle, who noted considerable temporary enlargement of the thyroid gland. At the end of eight weeks he had been allowed up some days, and travelled 570 miles to Wynberg. The aneurism was about 1-1/2 inch in diameter, smooth and rounded, extending just beneath the left clavicle and nearly the whole width of the sterno-mastoid, but well defined in all directions. There was well-marked expansile pulsation, purring thrill along the jugular vein and over the tumour, and loud machinery murmur widely diffused along the whole neck and into the thorax. The voice was still weak and husky, but there was no dysphagia or dyspnoea. The left pupil was larger than the right. The patient acquired enteric fever at Wynberg and when convalescent was sent to Netley, whence he returned home. The aneurism caused little discomfort. It may possibly have been of the inferior thyroid artery. (13) _Innominate arterio-venous varix_.--Wounded at Modder River. _Entry_ (Mauser) posterior margin of left sterno-mastoid, close above the clavicle. _Exit_ in anterior axillary line one inch below the right anterior axillary fold. Soon after the injury a considerable amount of blood was coughed up, and occasional hæmoptysis persisted for the next four days. The patient was moved from the Field hospital by train to Orange River, a journey of 55 miles and some four hours' duration, on the fourth day. When examined there was slight fulness over an area roughly circular and about 2-1/2 inches in extent, of which the sterno-clavicular joint lay just within the centre. Over this area there was faint pulsation with a strongly marked thrill and loud systolic bruit. The radial pulses were even, the right pupil larger than the left. No pain, and no dyspnoea. The right eye was partially closed, but could be opened by the levator palpebræ superioris. The patient was shortly afterwards sent to the Base, and when seen there twenty-five days after the injury, there was little change in the condition except that the fulness had disappeared, the thrill was more marked, and a typical machinery murmur transmitted along both carotid and subclavian arteries had developed. There was no headache and the man himself did not notice the bruit. Evidence of mediastinal hæmorrhage existed in the presence of subcutaneous discoloration of the abdominal wall, below the ensiform cartilage and extending slightly over the costal margin of the thorax. In the absence of an aneurismal swelling, or of the development of any further symptoms, the patient was sent home to Netley in January. I saw this patient in Glasgow a year later. He was employed as a lamplighter, and was able to do his work well, only complaining of attacks of shortness of breath on exertion. He said these were apt to come on each evening about 6 P.M. The pulse was 100 when the erect position was maintained, and 84 to 88 in the sitting posture. The right pupil was still dilated, reacting for accommodation but little to light. The palpebral fissure was normal in size and there was little, if any, diminution in strength of the right radial pulse. On inspection no pulsation was visible; in fact, the pulsation of the normal left subclavian was more apparent in the posterior triangle of that side. The sterno-mastoid was prominent, also the sternal third of the clavicle. On firm pressure some pulsation was palpable beneath the sterno-mastoid, but no definite evidence of the presence of a sac could be detected. Purring thrill and machinery murmur were still present, but the former was slight, and palpable only with the lightest pressure. The machinery murmur had ceased to be audible to himself, and was by no means loud or very widely distributed. The condition had, in fact, steadily improved, and become far less obvious. The prominence of the sterno-mastoid and clavicle still present was difficult of explanation, except on the theory of an injury to the bone, or that an aneurismal sac had consolidated spontaneously. (14) _Arterio-venous aneurism, root of right carotid._--Wounded at Magersfontein. _Entry_ (Mauser), centre of right infra-spinous fossa. _Exit_, 3/4 of an inch above clavicle, through point of junction of the heads of the right sterno-mastoid muscle. Range 200-300 yards. When wounded the man ran two hundred yards to seek cover. There was no serious external hæmorrhage, but the injury was followed by some difficulty in swallowing, and hæmoptysis, which lasted for the first two days. The right radial pulse was noted to be smaller than the left, and weakness in flexion of the fingers, with hyperæsthesia in the ulnar nerve distribution, was observed. The right pupil was also noted to be larger than the left. The patient was sent down to the Base, and on the twenty-fourth day the condition was as follows. A pulsating swelling existed extending 1-1/4 inch upwards beneath the right sterno-mastoid, from the mid line of the neck backwards to the centre of the posterior triangle, and downwards over 2 inches of the first intercostal space, which latter was dull on percussion. There was some evidence of a bounding wall, but it was thin and the tumour was soft and yielding. A loud machinery murmur was audible over the tumour, over nearly the whole extent of the thorax, and in the distal vessels as far as the temporal upwards, and the brachial as far down as the bend of the elbow. The murmur was audible to the patient with his ears closed. Over the swelling a strong thrill was palpable; this extended some little distance into the distal vessels and felt remarkably superficial. It was particularly evident in the line and course of the anterior jugular vein, and appeared to be extinguished by local pressure. Although readily felt in the posterior triangle, it was impalpable on deep pressure in the suprasternal notch, a fact which seemed in favour of localising the aneurismal varix to the subclavian artery and vein. The right pulse was good, although smaller than the left, and was said to have improved in volume. The right pupil was slightly larger than the left, but reacted normally. There was no pain or difficulty in swallowing. Weakness in power of flexion of the fingers persisted, and there was some impairment of sensation in the area of distribution of the ulnar nerve. Three weeks later no material change had occurred, except that the swelling was perhaps softer and the thrill more superficial, and at the end of two months the patient was sent to England. I saw this patient a year later in Glasgow, when the condition was as follows. He was living at home, and out of employment. He complained of shortness of breath on exertion, and said that when he mounted stairs he felt 'as if his heart were going to leave him.' The heart's apex beat in the sixth interspace in the nipple line, and the precordial dulness was somewhat increased. The pulse numbered 80 to 84. The muscles supplied by the ulnar nerve were very weak, but not much wasted, and ulnar sensation was imperfect. The aneurism had considerably altered in form and outline; its walls were dense and firm; it extended 2-1/2 inches upwards in the line of the carotid artery, beneath the sterno-mastoid, but projected beyond the posterior border of that muscle. The larynx was displaced 1/2 an inch to the left of the median line; the voice was still husky, although much stronger than it was; the anterior jugular vein was dilated. The purring thrill was very superficial, and chiefly palpable over the subclavian vessels. The machinery murmur was still loud, but much less widely distributed than before; it was still audible to the patient when he lay on his right side. This case was of much interest from the diagnostic point of view. When I first saw the patient I considered the injury to have implicated the innominate vessels. Later, from the facts that the thrill was imperceptible in the episternal notch, and that the main part of the tumour was situated in the posterior triangle, that the wound was of the root of the right subclavian vessels. It now appears that, at any rate, the root of the right carotid is the artery implicated. In spite of the continued existence of a large aneurism, the localisation of the sac, which had taken place, was very striking, considering that the man had been walking about freely, and living an ordinary life, except that he had undertaken no work. (15) _Popliteal arterio-venous aneurism_.--Wounded at Paardeberg. _Entry_ (Mauser), at lower margin of patella. _Exit_, at centre of back of thigh. Perforation of lower end of femur. The patient was lying down with crossed knees when the injury was received. Much oedema of the foot and leg followed the injury, and on the third day a thrill was discovered. Three weeks later there was still some swelling of the calf, the posterior tibial pulse was imperceptible, the anterior very small. An aneurism was palpable at the inner part of the top of the popliteal space, about the size of a pigeon's egg; a strong thrill was to be felt, especially when the knee was flexed, and with this expansile pulsation and a loud machinery murmur. The entry wound was firmly healed; the exit still furnished blood-stained serous discharge. The synovial cavity of the knee was distended and doughy on palpation. During the next three weeks the aneurism contracted considerably and the patient was sent home. When admitted to the Herbert Hospital the patient complained chiefly of pains in the foot and leg. The aneurism was cured by ligation of the vein above and below the communication and proximal ligature of the popliteal artery.[15] (16) '_Femoral arterio-venous aneurism._--A private of the West Yorkshire Regiment was hit on February 11, 1900, at Monte Christo by a bullet which passed through the inner border of his right thigh above its middle. On arrival at Woolwich the patient was found to have a varicose aneurism at the upper end of Hunter's canal. On May 31 the femoral artery was ligatured just above its communication with the vein, and as this stopped all pulsation in the vein, it was decided to postpone ligature of the latter to a subsequent occasion, if it should ever be necessary; such a procedure would, it was thought, interfere less with the circulation of the limb, and would therefore be less likely to be followed by gangrene, which is so frequent a result of high ligature of the femoral. But a few days after the operation the foot became cold and mummified, and there was no alternative but to amputate the limb through the condyles of the femur. From this operation the patient made a good recovery, and when discharged there was no sign of an aneurism of the vein.' Case 16 is quoted from a paper in the _Lancet_ by Lieut.-Colonel Lewtas, I.M.S. It illustrates a result with which I became acquainted in three other instances not under my own observation. ANEURISMAL VARICES (17) _Axillary._--Wounded at Modder River. _Entry_ (Mauser), at inner margin of front of left arm, just below level of junction of axillary fold. _Exit_, at about centre of hollow of axilla. A month later when the wound was healed a typical thrill and machinery murmur were noticed. The latter was audible down to the elbow and upwards into the neck. The radial pulse appeared normal. No swelling or pulsation existed. At the end of three months the condition was unaltered; the patient said he noticed nothing abnormal in his arm, except that it was sometimes 'sort of numb' at night. (18) _Popliteal._--Wounded at Magersfontein. _Entry_ (Mauser), in centre of popliteal space. _Exit_, about centre of patella, which latter was cleanly perforated. Three weeks later the typical thickening of the knee-joint following hæmarthrosis was present, also a well-marked thrill and machinery murmur in the popliteal vessels with no evidence of a tumour. The leg was normal except for slight enlargement of the internal saphenous vein and its branches, probably independent of the arterial lesion. (19) _Femoral._--Wounded at Magersfontein. _Entry_ (Mauser), 7 inches below left anterior superior iliac spine. _Exit_, at inner aspect of thigh. One month later slight fulness without pulsation was discovered on the inner side of the femoral vessels just above the level of the wound track. Some blood-staining still remained in the fold between the scrotum and thigh. Machinery murmur and a well-marked thrill, most palpable to the inner side of the superficial femoral artery, were noted. No further symptoms developed and the patient was sent home. _Prognosis and treatment._--No one can help being struck with the disinclination shown by the older surgeons to interference in cases of either aneurismal varix or varicose aneurism, even after the time that ligation of the vessels had become a favourite and successful operation. The objections lay in the technical difficulties of local treatment, and the danger of gangrene after proximal ligature. Modern surgery has lightened the difficulties under which our predecessors approached these operations, but none the less the experience in this campaign fully supports the objections to indiscriminate and ill-timed surgical interference, as accidents have followed both direct local and proximal ligature. In _pure varix_ no doubt can exist as to the advisability of non-interference in the early stage, in the absence of symptoms. This is the more evident when we bear in mind that a stage in which an aneurismal sac exists can seldom be absent. In many cases an expectant attitude may lead to the conviction that no interference is necessary, especially in certain situations where the danger of gangrene has been fully demonstrated. In connection with this subject I cannot help recalling the first case of femoral varix that ever came under my own observation. I discovered the condition accidentally in a man admitted into the hospital for other reasons. The patient remarked: 'For heaven's sake, sir, do not say anything about that. I have had it many years, and it has never given any trouble. If it is known, I shall be worried to death by people examining it.' None the less it must be borne in mind that beyond enlargement of the vein dilatation of the artery above the seat of obstruction does occur, and gives trouble in some situations. Again the disturbance of the general circulation already adverted to shows that the existence of this condition is sometimes of importance in its influence on the cardiac action. Under these circumstances the treatment varies with regard to the vessels affected, and the degree of disturbance the condition gives rise to. With regard to locality, experience appears to have shown clearly that communications between the carotid arteries and jugular veins usually give rise to so little serious trouble that, in view of the grave nature of the operation and its possible after consequences on the brain, interference is as a rule better avoided. I should, however, be inclined to draw a distinction between operations on the common and internal carotid arteries in this particular, and should regard varix of the latter vessel and the internal jugular vein as especially undesirable for interference. The vessels at the root of the neck are probably to be regarded from the same point of view, as to surgical interference. The arteries of the upper extremity are the most suitable for operation, and the axillary may perhaps be the vessel in which interference is most likely to be useful. In this relation it may be of interest to include here a case of a man who took part in the campaign when already the subject of an aneurismal varix of the axillary artery. (20) Twenty years previously the patient suffered a punctured wound of the left axilla from a pencil. A varix developed, but was only discovered by accident ten years later. The patient was seen by several surgeons, and treatment was discussed; the balance of opinion was, however, in favour of non-interference, and nothing was done beyond giving injunctions as to care in the use of the limb. Up to the time of discovery of the varix no inconvenience had been felt, although the patient was of athletic habits. Subsequently, the patient himself was positive that a swelling existed, but he pursued his usual work. In 1899-1900 he took part in the operations in South Africa as a combatant, and during this time was subjected to very hard manual work. During this he was seized with sudden pain in the left side of the head and neck, and in consequence invalided. No restriction in the movements of the upper extremity, and no subcutaneous ecchymosis developed, but the patient was positive as to the tumour having greatly enlarged. Four months later the condition was little altered. A pulsating swelling 1-1/2 inch broad existed along the line of the upper two-thirds of the axillary artery, and along the subclavian in the neck, rising some 1-1/2 inch into the posterior triangle. Pulsation was visible; the murmur was audible when sitting beside the patient, and widely distributed over the whole chest, the neck, and upper extremity on auscultation. The pulse rate varied with the mental condition of the patient, which was excitable, between 96 and 120. There was neuralgic pain in the neck and scalp, and down the distribution of the brachial plexus. The pupils were equal, but flushing of the face and profuse sweating followed any exertion. I concluded the tumour in this case to be mainly due to dilatation of the trunk above the point of obstruction on account of its outline, the absence of any restriction of movement in the upper extremity, and the non-occurrence of subcutaneous ecchymosis at the time of the attack of severe pain. Difficulties arose as to undertaking any active form of treatment for this patient, which, to be satisfactory, needed an antecedent period of absolute rest, and he passed from my observation. I think, however, operation by ligature above and below the communication would have been possible. The case affords a good example of the course the condition may sometimes take if precaution is neglected. The vessels of the arm or forearm may in almost all cases be interfered with, but in many instances an absence of any serious symptom renders operation unnecessary. With regard to the femoral varices, I would refer to the remarks below, and those on the treatment of varicose aneurism as indicating that a certain amount of caution should be exercised in interfering with them. The same remarks in a lesser degree apply to the popliteal vessels. In the leg the tibials may readily and safely be attacked, but it may be mentioned that the widespread and diffused nature of the thrill may in some cases give rise to considerable difficulty in sharp localisation of the varix to either of the vessels, or to any particular spot in their course. In one case in my experience the posterior tibial was cut down upon, when the varix was probably peroneal in situation. The operation most in favour consists in ligation of the artery above and below the varix, the vein remaining untouched. Even this operation, however, in two cases of femoral varix failed to effect more than a temporary cessation of the symptoms, although the ligatures were placed but a short distance from the communication. Failure is due to the presence of collateral branches, which are not easy of detection. Even when the vessels lie exposed, the even distribution of the thrill renders determination of the exact point of communication difficult, and the difficulty is augmented by the temporary arrest of the thrill following the application of a proximal ligature to the artery. A successful case is reported by Deputy Inspector-General H. T. Cox, R.N., in which the ligatures were placed 1/2 an inch from the point of communication.[16] Single ligation, or proximal ligature, is useless. If the vein cannot be spared, excision of a limited part of both vessels may be preferable, particularly in those of the upper extremity. Proximal ligation of the artery combined with double ligature of the vein, as adopted in case 15 by Colonel Lewtas for a varicose aneurism, might offer advantages in some situations. Given suitable surroundings and certain diagnosis, the ideal treatment of this condition, as of the next, is preventive--_i.e._ primary ligation of the wounded artery. Many difficulties, however, lie in the way of this beyond mere unsatisfactory surroundings. It suffices to mention the two chief: uncertainty as to the vessel wounded, and the necessity of always ligaturing the vein as well as the artery in a limb often more or less dissected up by extravasated blood, to show that this will never be resorted to as routine treatment. _Arterio-venous aneurism._--Many of the remarks in the last section find equal application here, but in the presence of an aneurismal sac non-intervention is rarely possible or advisable. In the early stages the proper treatment in any case consists in placing the patient in as complete a condition of rest as possible, and affording local support to the limb by a splint, preferably a removable plaster-of-Paris case. Should no further extension, or, what is more likely, should contraction and diminution occur, it will be well to continue this treatment for some weeks at least. When the aneurism has reached a quiescent stage the question of further treatment arises, and whether this should consist in local interference or proximal ligature. The answer to this mainly depends on the size and situation of the vessels concerned. To take of the cases above described the five instances in which the cervical vessels were the seat of the aneurism. In No. 13 the symptoms appeared fairly conclusive of the injury being to the innominate artery and vein, or possibly innominate artery and jugular vein. Fortunately the aneurismal sac in this case was small and showed a tendency to decrease, but in any case no interference would have been justifiable. I think a similar opinion was unavoidable in No. 14, probably affecting the root of the right carotid. Here under any circumstances interference would have been most hazardous. The position of large aneurism made the route of approach to the wounded spot necessarily through the sac, exposing the patient to the double danger of immediate hæmorrhage and of entrance of air into the great veins. Nos. 10, 11, and 12 fall into the same category, except that in No. 11 the immediate indication for interference was extension. In each, ligature of the artery above and below the point of communication would have necessitated so near an approach to the sac which must remain in communication with the vein as to have entailed injury to the latter, when both artery and vein must have been ligatured, probably risking serious cerebral trouble. In No. 11 I believe both the external and internal carotids were implicated; in No. 10 I believe the internal alone, close to its origin. The operation of proximal ligature ensured primary consolidation of the sac in both cases 10 and 11, but left the thrill unaltered, except in so far as it was temporarily weakened. It, in fact, converted these cases from arterio-venous aneurisms into pure aneurismal varices. In No. 10 a sac subsequently redeveloped. No. 12 stood on a different basis. No operation was done for him in South Africa, but the first portion of the carotid might have been ligatured in the episternal notch, or by aid of removal of a part of the sternum, and a second ligature placed above the sac. Here a ligature above and below the communication would have been comparatively easy. As a general rule proximal ligature is to be reserved for those cases alone in which double ligature is either impracticable or inadvisable, and it can only be expected to convert a varicose aneurism into the less dangerous condition of aneurismal varix. In the case of arterio-venous aneurisms in the limbs the possibilities of treatment are enlarged, and here the alternatives of (_a_) local interference with the sac and direct ligature of the wounded point, (_b_) simple ligature above and below the sac, (_c_) proximal ligature (Hunterian operation), come into consideration. Direct incision of the sac is suitable, and the best method of treatment for aneurisms in the calf, forearm, and probably arm. Several cases in the two former situations were successfully treated by this method. On the other hand, the only case I saw in which a proximal ligature had been applied for an arterio-venous aneurism of the leg resulted most unsatisfactorily. The sac in the calf suppurated at a later date, and for many weeks the escape of small quantities of blood from the remaining sinus kept up the fear of a severe attack of secondary hæmorrhage until the sinus closed. In the case of femoral and popliteal aneurisms the method of Antyllus is often unsuitable. A case of arterio-venous aneurism of the femoral artery quoted in the _Lancet_[17] will illustrate the difficulty which may be met with in determining the actual bleeding point in the irregular cavity laid open. In any case the necessary ligature of both artery and vein is a serious objection to the direct method either in the thigh or ham, and more particularly if adopted before the damage dependent on the dissection of the limb by extravasated blood has been repaired. Proximal ligature (Hunterian) even, offers dangers under these circumstances. In one case with which I became acquainted, it was followed by gangrene, necessitating amputation. The lesion in this instance was a perforating one of the femoral artery and vein. For either femoral or popliteal arterio-venous aneurisms ligature of the artery above and below the aneurism is the best and safest treatment. In view of the healthy state of the vascular wall in most of these cases, the advantage of placing the ligatures as near to the wounded spot as can be managed without interference with the sac is afforded. A number of popliteal cases treated in this way did perfectly. In the femoral cases a considerable period of rest to allow of consolidation of the sac, and readjustment of the circulation, should always be allowed to elapse. In the case of popliteal arterio-venous aneurisms a number were successfully treated by proximal (Hunterian) ligature, and by single ligature immediately above the sac. In a considerable proportion of the latter both artery and vein were tied. This was apparently the result of the difficulty of isolating the vessels in the tangled mass of clot and cicatricial tissue surrounding them, and is a strong argument against too early interference. The late Sir William Stokes expressed himself as in favour of ligature of the artery in Hunter's canal, combined with that of the great anastomotic branch, and quoted some successful cases to me. I have grave doubts, however, whether the varix can often be permanently cured by this operation. I can give no useful statistics on this subject, but with regard to the popliteal aneurisms I may state that in three instances gangrene of the leg followed early operative interference in the popliteal space. My own opinion on this subject is strong, and to the effect that none of these operations should be undertaken before a period of from two to three months after the injury, unless there is evidence of progressive enlargement. In every case which came under my own observation progressive contraction and consolidation took place up to a certain point under the influence of rest. When this process has become stationary, and the surrounding tissues have regained to a great extent their normal condition, the operations are far easier, and beyond this more likely to be followed by success. It appears to me that one argument only can be raised against the above opinion, viz. the possibility of healing of the recent wound in the vessels when the force of the circulation is lowered by proximal ligature. Such experience as that quoted from Sir W. Stokes and two of Mr. Ker's cases, mentioned below, support this possibility, but in all the reported results were recent. Against them I can only advance my knowledge of several mishaps following early operation. In concluding these observations on injuries to the arteries and aneurisms, a few general remarks as to the occurrence of gangrene after operation must be added. This was not uncommon, and in the main was no doubt attributable--(1) to the lowering of the vitality of the surrounding tissues by creeping blood extravasation, and sometimes to actual pressure by the extravasation on the vessels necessary for the establishment of the collateral circulation. (2) To the frequency with which both artery and vein required to be ligatured. Beyond these common causes, however, others must be advanced, dependent on the general and local condition of the nervous system in these cases. In general mental state many of the patients were much shaken, and in others the condition spoken of as local shock in a former chapter had been marked. In a third series obvious individual nerve lesions were co-existent with those to the vessels. Beyond this a fourth nervous element of unknown quantity, the effect of the form of injury on the vaso-motor nerves accompanying the great vessels, must be taken into consideration. I believe all these factors were of importance, since it appeared to me that gangrene occurred more often than I should have expected. In one case which I have heard of, gangrene followed a very slight injury to the foot in a patient who had apparently made an excellent recovery after ligature of the femoral artery. The nervous factor seems another element in favour of reasonable delay in active interference with traumatic aneurisms of the above varieties in the absence of threatening symptoms. It is worthy of remark that no case of gangrene due to aneurism came under my notice, except subsequently to operation. Since the above chapter was written, my friend, Mr. J. E. Ker, has sent me his experience in the treatment of four aneurisms, which is of such interest that I insert it as an addendum. _Arterial hæmatomata._--(1) Popliteal, treated by local incision. Both artery and vein completely divided. Ligature of the four ends. Cure. (2) Traumatic aneurism of upper third of forearm. Treated by rest and pressure by bandage. On the eighth day pulsation and bruit ceased spontaneously, and the remains of the sac steadily consolidated until the man's discharge on the twenty-sixth day. _Arterio-venous aneurisms._--(1) At junction of brachial and axillary arteries. Proximal ligature. Cure. (2) Arterio-venous aneurism at the bend of the elbow. Ligature of the brachial at the junction of the middle and lower thirds of the arm. Cure. FOOTNOTES: [14] The murmur is still present at the expiration of one year, but no other change. [15] Lieut.-Colonel Lewtas, I.M.S. See _Lancet_, 1900, vol. ii. p. 1073. [16] _Lancet_, 1900, vol. ii. p. 1074. [17] Sir W. MacCormac, _Lancet_, vol. i. 1900, p. 876. CHAPTER V INJURIES TO THE BONES OF THE LIMBS Injuries to the bones of the limbs formed a very large proportion of the accidents we were called upon to treat, and afforded as much interest as any class, since they possessed many special features. I shall hope to show, however, as in some of the other injuries, that these features differed only in degree from those exhibited by injuries from the old leaden bullets of larger calibre, although with few exceptions they were of a distinctly more favourable character. It is of considerable interest to note that, taking the fractures as a whole, there was a somewhat striking change in their nature during the earlier and later portions of the campaign. In the earlier stages I think there is no doubt that punctured fractures were proportionately more common than in the later, when comminuted fractures were much more often seen. There was, I believe, a source of error in this opinion, as far as I myself was concerned, in that the first cases I saw were at Capetown and had come from Natal. There is no doubt that the punctured fractures were earlier fit to travel, and hence a larger number of them found their way to the Base hospitals at a period when the comminuted fractures were still in the Field or Stationary hospitals. I do not, however, rely on the cases seen at Capetown alone for my opinion, as while at the front I saw the same large proportion of clean punctures in the early engagements of the Kimberley relief force. I am inclined to attribute the change to two reasons: first, I believe that the use of regulation weapons was more universal in the earlier part of the war, while later, as more men were engaged, the Martini-Henry came more into evidence, and the Boers took more freely to the use of sporting rifles and ammunition. Another element also in the less clean punctures of the short and cancellous bones was probably the less accurate and hard shooting of the Mauser rifles as they became worn; the bullets seemed to evidence this by the comparative shallowness of their rifle grooves, which, I take it, would mean less velocity and accuracy in flight. This would be of importance, since the clean puncture of cancellous bone was no doubt favoured by a high rate of velocity. The special features of the fractures caused by the small-calibre bullets were: (1) The nature of the exit wound, which in a certain proportion of the cases exhibited the so-called 'explosive' character. (2) The presence, in a marked degree in the severe cases, of the condition spoken of in Chapter III. as 'local shock.' (3) The striking contrast of clean perforation and extreme comminution in different cases. (4) The occasional occurrence of fractures of a very high degree of longitudinal obliquity. (5) The rarity of any that could be termed transverse fractures. (6) The general tendency of longitudinal fissuring when it occurred to stop short of the articular extremities of the bones. It will perhaps be most convenient to consider first the explanation of the development of the so-called explosive apertures, and then to pass on to a general consideration of the types of fracture commonly met with, before proceeding to the description of the injuries to the separate bones. _Explosive wounds in connection with fractures._--The aperture of entry in these injuries presented little or no deviation from the normal, unless it was due to the passage of ricochet bullets, when it might be very irregular, but usually not of great size. [Illustration: FIG. 47--(21) 'Explosive' Exit Wound of Forearm over margin of ulna. Note creased tongue of skin originally covering whole wound. The entry wound was a small typical circular one] The aperture of exit offered special features beyond simple increase in size. First of all, as in the small type wounds, the actual extent of destruction of the skin was small, this having been projected outwards by the passing bullet and then either burst or torn by the bullet and accompanying bony fragments. Fig. 47 well illustrates this feature. A triangular tongue of skin was lifted by the passing bullet and probably by the lower end of the upper fragment of the fractured ulna; through the resulting opening a mass of soft tissues and bone fragments, bound together by an infiltration of coagulated blood, was extruded, separating the lateral lips of the aperture, while the original tongue has shortened and retracted up to the top of the wound. The small extent of skin actually destroyed is an important element in the rapid contraction often seen in these wounds when they progress favourably. Thus the large wound portrayed in fig. 48 contracted to one-fourth its original size ten days after the diagram and measurements were made. The large mass of protruded tissue was often most striking when a muscle such as the biceps in fig. 48 had been divided; but the herniæ were more persistent when the mass projected in regions where tendons formed a large integral constituent, as at the wrist or lower third of the forearm. The protruding tissues naturally consisted of many varieties, according to what lay in the track of any particular wound. It should be added that for 'explosive' features to reach their strongest development, it is necessary that the bone affected should lie near the surface of the body; hence the most characteristic explosive wounds were met with in the forearm or leg, over the metacarpus or metatarsus, or in the arm. In the thigh, on the other hand, where the femur in a great part of its course not only lies deeply, but is also protected by particularly strong and resistent skin and fascia, another type of wound was met with. The explosive exit aperture, although large, was still only moderate in extent, sometimes, as in the front of the lower third, exposing a somewhat angular large track walled by the divided quadriceps extensor cruris. In other cases, on introducing the finger through a moderate exit opening on the inner aspect of the thigh, a large cavity, sometimes 4 or 5 inches in diameter, was discovered, full of clot and shreds of destroyed tissue and lined by a layer of similar material. In either of these latter cases the fractured bone ends were situated too deeply to take part in the actual laceration of the skin, while the force transmitted to the bone fragments, although sufficient to cause them to widely destroy the first soft tissues met with, did not suffice to cause them to burst or lacerate the skin widely. [Illustration: FIG. 48.--(22) 'Explosive' Exit Wound of front of Arm. Wound actual size eight days after its infliction. The prominences in the upper and lower parts correspond with the lacerated biceps. The dark crater led down to the fracture. In another week the wound had contracted to half the size. The entry aperture was a normal circular one. The arm a year later was used in the patient's employment as a hammer-man.] With regard to the theories of the production of these phenomena, that of the transmission of a part of the force of the bullet to the comminuted fragments, which thus themselves acquire the characters of secondary projectiles, seems quite adequate.[18] Examination of any of the skiagrams in which considerable comminution has taken place, shows that the fragments are carried forward and perforate the tissues distal to the fracture. [Illustration: FIG. 49.--'Explosive' Wounds of Legs. Large irregular entry (1 × 3/4 in.). First exit (2 in.) roughly circular. Second entry wound, produced by bone fragments driven out of left leg, very large and irregular (5 × 3-1/2 in.). The measurements were taken eight days after infliction of the wounds. The right limb was amputated later for secondary hæmorrhage] Fig. 49, although a poor delineation of the actual condition, shows well the possible action of projected fragments, even after they have been driven from the wound. In this case either a large or a ricochet bullet entered on the outer aspect of the upper third of the left tibia; it produced a severe comminuted fracture, the fragments from which, together with the deformed bullet, then struck and perforated the upper third of the right tibia. A large irregular entry wound 5 inches in transverse diameter was produced in the second limb together with a comminuted fracture of the bone. The right limb had eventually to be amputated for secondary hæmorrhage, but I am unacquainted with the later history of the patient. The mode of displacement of the lateral fragments when a wide shaft such as that of the femur is struck, throws some light on that of the displacement of soft tissues such as the component parts of a perforated nerve or artery. The bullet, passing through, expends the chief part of its energy in driving before it the fragments produced in its direct course, while a minor part of the energy is expended on displacing the lateral fragments, which are pushed to either side without becoming separated from their periosteal attachment. The appearance, in fact, somewhat suggests what might be expected were a small charge of dynamite introduced into the centre of a small tunnel made across the shaft of the bone. Examination of some of the skiagrams also illustrates another point of interest, viz. that a certain degree of recoil on the part of the bone results from the blow, since in many of them portions of the mantle of the bullet and bone fragments are seen in that portion of the track proximal to the fractured bone. The importance of 'setting up' of the bullet is at once evident in relation to the production of wounds of an explosive type in connection with fractures of the bones. There can be no doubt that a considerable number of the most severe injuries we saw were produced by the various soft-nosed or expanding forms of bullet, also that others of an equally serious nature were produced by Martini-Henry or large leaden sporting bullets. Allowing for this, however, I think a considerable proportion were the result of deformation from bony impact, or ricochet deformities external to the body acquired by regulation Mauser bullets, and I think these bullets can be quite as formidable as any of the sporting varieties met with. The soft-nose varieties of small calibre may not set up enough to cause severe injury, while the large leaden bullets often flatten out so completely as to lose all penetrating power. As far as my impressions went, the small soft-nosed bullets needed to be travelling at a very considerable rate of velocity to be dangerous. In the form of soft-nose Mauser employed, the soft-nose was too short to allow of as successful a mushrooming of the bullet as often occurred with the regulation projectile, because, as already explained, the mantle acquires increased stability from its closed base. FRACTURES OF THE SHAFTS OF THE LONG BONES _Types of fracture._--The common types of fracture of shafts of the long bones are illustrated diagrammatically in fig. 50. Of the whole series comminuted fractures were by far the most frequently met with, while the various wedge-shaped forms were the most strongly characteristic of the special form of injury in which we are interested. [Illustration: FIG. 50.--Five Types of Fracture: A. Primary lines of stellate fracture; wedges driven out laterally and pointed extremities left to main fragments. B. Development of same lines by a bullet travelling at a low degree of velocity; suppression of two left-hand limbs and substitution of a transverse line of fracture; a spurious form of perforation. See plate XXIII. C. Typical complete wedge. See plate VII. D. Incomplete wedge; impact of bullet, lateral or oblique, and two left-hand lines seen in A are suppressed. E. Oblique single line, one right and one left hand line seen in A, suppressed. The influence of leverage from weight of the body probably acts here. Compare plates XVI. and XXI.] [Illustration: PLATE III. Skiagram by H. CATLING Engraved and Printed by Bale and Danielsson Ltd. (23) SPURIOUS PERFORATION OF CLAVICLE Range unknown, probably either mean or long. The bullet entered from the front, grooved the under surface of the acromial end of the clavicle with increasing depth, and eventually perforated the posterior margin of the bone, raising the compact tissue in an angular manner. The commencement of an incomplete groove extending from the anterior margin is seen, resembling the groove of the humerus, fig. 58.] 1. _Stellate comminuted fractures._--A shows the primary nature of the lesion in all comminuted fractures of compact bone, consisting in the production of a number of radiating fissures, which assume a stellate form of which the point of impact corresponds to the centre. B shows an incomplete development of this form, the fragments being simply displaced laterally with slight loss of substance, so as to simulate a real punctured fracture. An illustration of this fracture produced by a bullet travelling at a low degree of velocity is seen in plate XXIII., which also shows the unaltered bullet lying in close proximity to the injured fibula. The degree of comminution in these fractures depends first on the range of fire and consequent striking force retained by the bullet, a high degree of velocity producing extreme comminution of compact bone. The severity of the latter again may be influenced by the measure of resistance dependent on the density and brittleness of any individual bone, or on the possession of the same characters as a special property by the tissues of the man struck. Thus plate IV. shows a fracture of the humerus produced by a bullet shot from a short range, and the fragments are comparatively large and of even dimensions, while plate XIV. shows extreme comminution of the portion of the femur exposed to direct impact, with elongated large fragments at the sides of the track. Plate XIX. shows less extreme comminution and less separation of the fragments, and was probably produced by a bullet from a longer range of fire. The separation of elongated lateral fragments is a special feature, and best marked when the portion of bone struck is considerably wider than the bullet, as in the case of the shaft of the femur. These fragments correspond in the method of their production to those seen in the wedge fractures described below, while their separation leaves a pointed extremity to either segment of the shaft. This fracture in its purest type is, I believe, spoken of as the 'butterfly fracture.' With regard to the spread of the fissures in the long axis of the bone into neighbouring articulations I think fractures produced by bullets of small calibre differ considerably from those produced by larger projectiles, in that their general tendency is not to extend beyond the commencement of the cancellous bone forming the joint end. This is perhaps capable of explanation on several grounds: first, the smaller area of impact results in the assumption of a strongly marked stellate figure, the radiating fissures of which rapidly reach the lateral limits of the shaft, producing a solution of continuity in the bone which interrupts the continuance of the action of the wedge represented by the bullet. Secondly, the small size of the wedge itself is opposed to the wide separation of the parts directly implicated, which is necessary for the continued progress of the process of fissuring, and again the rapidity of passage minimises the period during which the force is exerted. It is in these points that I believe the chief differences between the modern and old gunshot fractures find their explanation, since with the larger bullets fractures extending from some distance into the joints were a somewhat special feature. In addition it is probable that the alteration in structure at the junction of the shafts with the cancellous ends also tends to check the regular extension of the fissures, as a similar limitation is illustrated even in some fractures by Snider bullets. Fig. 51 of the lower end of the femur illustrates a not uncommon lower limit to a comminuted injury in this region. [Illustration: FIG. 51.--Lower end of Femur. From Case needing amputation. It shows the usual tendency of the fissures to stop short of the articular ends of the long bones] The degree and nature of the comminution also vary with the directness of impact on the part of the bullet. The more nearly this approaches at a right angle, the more severe is the local comminution, but probably a lesser area of the shaft is implicated. Plate V. shows an example of this: all trace of continuity is lost, a wide gap separates the bone ends, while the fragments themselves have been for the most part driven altogether out of the wound. Oblique impact, on the other hand, may widen the comminuted area at the point of impact, while, if the bullet retains sufficient force and regularity of outline, it may then travel 'cutting its way' through the remainder of the bone in an oblique direction. It will be of course recognised that the exact impact of the bullet depends not alone on the direction of the projectile, but also on the nature of the slope offered by the surface of bone struck. 2. _Wedge fractures._--This form (C and D, fig. 50) is equally characteristic of gunshot injury with pure perforation; it is met with in two varieties. C illustrates the more strongly marked type; in it the bullet makes passing lateral impact with the shaft, and from the point struck radiating fissures extend to the opposite margin, so that a wedge-shaped piece of bone often secondarily comminuted is separated from the remainder of the shaft; see plate X. of the radius. The second variety, D, is an incomplete development of the stellate fracture in which the fissures pass to one margin of the bone only. The explanation of this variation is probably to be sought in the direction of impact on the part of the bullet, since the main fissure is often accompanied by secondary lines which run a somewhat parallel course to the main one, and suggest the dispersion of the force in the form of concentric waves. Such fractures were most strongly marked in the tibia, the breadth of the surfaces of this bone presenting especially favourable conditions for their production. 3. _Notched fractures._--These may be a slight degree of the form of wedge fracture last described; such a one is depicted in plate XXII. where a portion of the spine of the tibia has been carried away by a passing bullet. Other notched fractures approximate themselves more nearly to perforations, the notch being a groove secondary to the opening up of such a track as is shown in the illustration of a perforation of the lower third of the shaft of the tibia (fig. 57 on p. 219). Notching or grooving is naturally much more common in the cancellous portions of bones. 4. _Oblique fractures._--These also occur in two varieties: the first has been already alluded to; in it the bullet actually cuts an oblique track in the bone; the main line of fracture is often considerably comminuted, usually at the proximal end of the track (see plates XV. and XIX.). The second variety (E, fig. 50) is less common; in it two of the main limbs of the simple stellate figure are suppressed, while the remaining two form a continuous line from one margin of the shaft to the other, the point of impact lying approximately in the centre of the line of fracture. Such a fracture is illustrated by the skiagram of a femur in plate XVI. in which the bullet traversed the soft parts transversely at the level of the centre of the fracture, which was 9 inches in length. In another case the line of fracture occupied the lower third of the femur, passing from the inner border of the shaft, the lower end of the upper fragment was formed by the compact tissue forming the outer wall of the external condyle. This latter perforated the vastus externus and lay beneath the skin; as it could not be disentangled, an incision was made over it, and the fragments when reduced were screwed together by Mr. S. W. F. Richardson. In neither fracture was there any comminution. Such fractures most nearly resemble the oblique or spiral ones met with in civil practice as the results of falls. In all the instances I observed the patients were supported on the lower extremities at the time of the accident, and one can only assume that a twist of the trunk consequent on the fall of the body diverts the most forcible vibrations resulting from the impact of the bullet into one line, and thus produces a solution of continuity of a simple oblique nature. In both the cases mentioned above the bullet was probably travelling at a low degree of velocity; in the first it was a ricochet and was retained. I never saw one of these fractures in the upper extremity. Plate XXI. affords an excellent example of this mechanism. The patient was standing when struck, and then fell backwards. An incomplete fissure 7 inches in length is seen to extend from an otherwise pure perforation of the shaft of the tibia. 5. _Transverse fractures._--Throughout these were of very rare occurrence. Plate XX. illustrates a pure transverse fracture produced by passing contact of a bullet probably fired at a distance not exceeding 400 yards, and which subsequently struck the fibula plumb and produced considerable comminution. No fissure extended into the ankle-joint. Comminutions such as that illustrated by plate V. more or less simulated transverse fractures, but I saw no examples of transverse tracks comparable to the oblique ones described above 'cut through' the shaft of a bone. 6. _Perforations._--Although these were common in cancellous bone, they were comparatively rare in the compact shafts. I saw, however, complete pure perforations of the shafts of the tibia, femur, clavicle, and other bones. These perforations were, I believe, always the result of low degrees of velocity, and they took the place of simple transverse fractures of the 'cut' variety. The apertures of entry and exit in the bones resembled in character those seen in the soft parts, or in the bones of the skull in low-velocity injuries (see figs. 71 and 72, p. 261). The entry was more or less cleanly cut, while at the exit a plate of bone was raised, and either separated or turned back on a hinge by the bullet (fig. 52), (plate XVII.) Such a projecting hinged fragment was sometimes a source of some trouble; thus in a case of postero-anterior perforation of the lower third of the shaft of the femur, the long exit fragment projected into the substance of the quadriceps extensor muscle, and interfered with flexion of the knee-joint. Fig. 57 of a superficial tunnel of the lower third of the tibia is especially interesting as bringing such injuries of the long bones into line with fractures of the flat bones of the skull, such as are illustrated in fig. 68, p. 259. Plate XXI. affords an excellent example of perforation of the shaft of the tibia, although complicated by the secondary fissure. Plates XXIII., VIII., and III., of the fibula, humerus, and clavicle, exhibit examples of what may be called spurious perforations of the shafts of bones, since comminution or loss of continuity accompanies all three. Subsequently to writing the above paragraphs, I took the opportunity of re-examining the magnificent series of gunshot fractures collected during the Franco-German campaign by Sir William MacCormac, and afterwards presented by him to the museum of St. Thomas's Hospital. The close approximation in type between the main features in these and those in the fractures produced by the modern bullet is very striking. In the case of the shafts of the long bones, the same stellate, oblique, wedge-shaped, and even perforating injuries are illustrated on a coarser scale. In a specimen of a patella, a perforation of the lower half, implicating also the tendon of the quadriceps muscle is, though large, almost as pure as a Mauser perforation. The difference in the nature of the lesions of the bones is seen to be, firstly, one of pure magnitude, corresponding to the size of the large Snider bullet by which they were produced. Thus the fragments generally are larger, and occupy a wider area of the shafts, the first character depending on the lesser degree of velocity of the bullet, the latter on its volume and weight. Fine comminution, however, the most striking feature of the modern injury, is throughout absent. The effect of the larger size of the wedge provided by the bullet in increasing the length of secondary longitudinal fissures is well marked, and for the same reason the perforations are usually accompanied by fissures of considerable extent. It is interesting to note, however, that even in the case of the large bullets, and the special tendency shown by them to cause the extension of fissures into the joints, one or two specimens still show that these fissures incline to stop short when the point of junction between the portion of the shaft occupied by the medullary canal and that built on a foundation of cancellous tissue is reached. LESIONS OF THE SHORT AND FLAT BONES The above types of fracture are those common to the shafts of the long bones, but the difference in structure of the articular ends and the short and flat bones endows lesions of these with somewhat different characters, the nature of which varies between grooving, perforation, and great comminution. The most typical injury consists in the production of a clean perforation of the cancellous bone; this was common both in the articular ends and in the short bones. The tunnel differed little in character from those already described, a tendency always existing to the lifting of a lid of compact tissue at the exit end of the track. For the production of the cleanest forms of injury I believe high rates of velocity were distinctly favourable, although I am unable to maintain this statement by proof in the case of injuries received at the shortest ranges of fire. When the velocity was lower, yet with force still sufficient to produce a perforating injury, the separation of an extensive scale of bone at the exit aperture was a marked feature not seen in perforations produced by higher degrees of velocity. Fig. 52, of a perforation of the lower end of the femur, well exhibits this feature; but it must be borne in mind in this case that the illustration is not a pure one, both shaft and epiphysis taking part in the walls of the track, and the exit opening is in the former, where a thicker layer of compact bone exists than would cover any epiphysis, and hence the fragment is larger. I use the example, however, because it so forcibly illustrates the effect of increased resistance on the part of the bone struck in widening the area of the lesion. When the track was entirely limited to the articular ends the small amount of damage at either aperture was shown by clinical evidence in the rarity of subsequent limitation of joint movements due to bony deformity. [Illustration: FIG. 52.--Oblique perforation, implicating both epiphysis and diaphysis. Large fragment detached at exit aperture. Caused by a bullet travelling at a low rate of velocity. Compare with figs. 71 and 72 of a skull fracture. The dotted lines indicate the course of the track] Again, it was rare for fissuring to extend from these tunnels to the articular surfaces; thus many instances could be given of perforation of the head of the humerus, the olecranon, or the femoral condyles, in which no evidence of joint fissure was discoverable. The slight amount of resistance offered by the cancellous ends was also clinically illustrated by the absence of severe synovial effusions when they were struck. When the joint cavity was not crossed, slight effusion only resulted, while in the case of fractures of the femoral shaft great effusion into the knee-joint, resulting from the forcible vibration transmitted to the limb, was a common feature, even when the point fractured was situated above the centre of the bone. Again, when the joint cavity was crossed a moderate degree only of hæmarthrosis was the most common result. With regard to the implication of joints, either primary or secondary, in connection with fractures of the articular ends, I am inclined to place the lesions of the upper end of the tibia in a more important position than those of any other bone. Evidence of this implication was in my experience more frequent here than in any other situation. This may in part be attributable to the complexity of structure of this epiphysis, and perhaps more correctly to the influence of its irregular outline in favouring lateral forms of impact on the part of the bullet and consequent increase in the area of damage. Next to tunnelling, grooving was the most common form of injury to the short bones. In the case of superficial tracks the compact tissue might be considerably comminuted, but not, as a rule, over a width greatly exceeding the calibre of the bullet. Comminution and crushing of a single or several bones were rare in proportion to the occurrence of similar injuries produced by Martini-Henry or large leaden bullets. When the condition was produced by bullets of small calibre, I believe it was in the majority of cases the result of irregular impact on the part of the projectile. In support of this view it may be added that such injuries were most common in the bones of the tarsus, bones especially liable to be struck by ricochet bullets. It was generally believed that bullets travelling at a very high degree of velocity were liable to cause severe comminution of the short bones, but I never saw any cases supporting this opinion; in point of fact, all the short-range lesions of this nature that I saw were of the clean perforating variety. I believe that this is capable of satisfactory explanation on the ground of the thin character of the layer of compact tissue which for the most part ensheaths the short bones; this decreases the resistance offered to the bullet and so tends to localise the lesion. This statement may be supported by two observations with regard to the long and flat bones. First, if the shaft of a long bone be hit above the junction of diaphysis and epiphysis, the cancellous tissue in and extending from the medullary cavity is pulverised, and examination of fragments from such fractures gives the impression of the inner aspect having been scraped clean. Secondly, I saw one fracture of the ilium produced by a bullet taking a course between its compact layers for 3 inches from the notch between the anterior superior and anterior inferior spines; the bone to the extent of 2-1/2 square inches was pulverised, the cancellous tissue blown away as dust, and the compact tissue only represented by scales still adhering by their periosteum to the muscles attached to the two surfaces of the bone. This injury was produced from a rifle fired at five yards distance, and was an extreme example; but, on the other hand, it illustrates only what we are thoroughly well acquainted with in the case of flat bones, such as those of the cranium, where the compact element is abundant in comparison with the cancellous, and the resistance offered to the bullet is consequently great. Some remarks on transverse fractures of the patella will be found under the heading devoted to that bone. Lesions of the flat bones are considered at some length in Chapter VII., which deals with injuries to the head, and their special features are there described; some further remarks on these injuries will be found under the headings of the individual bones. _Special characters of the symptoms observed, and of the course of healing of the fractures._--Peculiarities in the initial signs may be rapidly passed over. The first depended on the large number of lesions of the bone which were unaccompanied by loss of continuity. In the case of perforations attention to the course of the track, external palpation, and possibly the detection of bone dust in the aperture of exit, were usually sufficient to indicate injury to the bones. When these did not suffice the introduction of a probe would usually set the question at rest; but this is always to be avoided if possible, as adding a fresh item of risk to the wound. The X rays were not always to hand, and are not always capable of giving reliable information in the matter of perforations, although very useful in detecting grooves or notching. The latter injuries are those in which information as to the condition of the bones is often of most interest in view of the characters of the external wounds. Fractures with solution of continuity were, as a rule, easy of detection, but the relative prominence of the classical signs varied somewhat from what we are accustomed to see in civil practice. The first striking peculiarity noted in comminuted fractures of the long bones was the degree of local shock; the limbs were often quite powerless, the muscles flaccid, and common sensation lowered. This was of importance in two ways; firstly, shortening of the limb was often absent as a sign, and, secondly, pain was sometimes not at all pronounced even when the patient was moved. The primary absence of shortening, even persisting for the first two or three days, was a phenomenon always important to bear in mind, as it affected the degree of extension needed in the treatment of the fracture, which, if sufficient at the moment, often proved quite inadequate with the return of tone in the muscles. Secondly, abnormal mobility was usually strongly marked, and this sometimes without very definite crepitus, as a result of the fine nature of the comminution and the displacement of the small fragments. During the course of healing some other peculiarities are worthy of mention. First of all, union was tardy and often not strong. On the other hand, an abundance of provisional callus was common, which formed large swellings apt to implicate neighbouring nerves, and sometimes to interfere with the movements of joints. The slowness of healing was particularly noticeable in those cases where the degree of local shock had been marked, and was probably to some extent dependent on disturbance of the general nutrition of the tissues of the affected limb. Beyond this, however, it was in many cases a direct result of the degree of comminution and displacement of the fragments, which necessitated the formation of a large amount of provisional callus, and time for the proper consolidation and contraction of the same. In many cases a large ball-like mass of callus surrounding the fragments was developed, into which the actual ends of the broken bone only dipped, and hence union was weak and insecure. As to those cases in which the wounds closed by primary union, we must bear in mind in this relation the tardy union often observed in civil practice, when the irritation of suppuration and consequent inflammation are absent. Another peculiarity of a similar nature was the occasional late necrosis of fragments; the wounds apparently healed well, only to break down weeks or months later for the discharge of a sequestrum. Such cases were quite distinct from those in which primary suppuration had occurred. I saw one or two instances in fractures of the humerus, the trouble arising with commencing use of the limb, and I suppose that fragments which suffered death at the time of the injury had been enclosed, and only caused irritation as foreign bodies when the muscles again came into action. In the absence both of evident necrosis and suppuration, however, in some cases the exit portion of the track in the soft parts was extremely slow in healing. Although no discharge beyond a small quantity of blood-tinged serum escaped, the wounds remained open for many weeks, even when the fracture consolidated well. I ascribed this to slow separation of aseptic sloughs, a point which has already been mentioned under the heading of wounds in general. Superabundance of callus, as far as I had an opportunity of judging, comparatively seldom gave rise to permanent mechanical trouble. This was no doubt due to the infrequency of extension of the comminuted fractures beyond the junction of diaphysis and epiphysis. Lastly, with regard to suppuration, only a small proportion of the fractures, accompanied by the presence of large wounds, escaped infection. When infection did occur, the results offered some special features dependent on the small relative amount of damage to the soft tissues, compared with that suffered by the bone. In an ordinary compound fracture, such as we meet with in civil practice, whether the result of direct or indirect violence, a considerable amount of contusion or laceration, as the case may be, accompanies the injury to the bone. The result of this is a widespread effusion of blood into the limb, which tears and strips up the various layers of soft parts, and opens up the way to the spread of infection, often into the whole length of the segment of the limb affected. In fractures produced by bullets of small calibre, even when the exit portion of the track is large, the injury to the soft parts is far more localised, except in extreme cases, while the bone itself is the tissue which has suffered the most severe violence and contusion. When infection occurred, its spread corresponded with this anatomical feature of the lesion, and the bone itself and its immediate neighbourhood suffered the most severely. At the present day one is naturally not very familiar with a large series of suppurating compound fractures, but during my whole experience I have never seen so many cases of what might be regarded as fairly pure instances of acute osteo-myelitis. The symptoms corresponded with the main seat of the suppuration; only moderate swelling of the limbs occurred, this mainly consisting in soft superficial oedema; often there was no redness, and fluctuation was difficult to determine. At the same time symptoms of constitutional infection, such as continued fever, rapid pulse, restlessness, loss of strength, progressive anæmia, and emaciation, were marked. Pyæmia, as evidenced by secondary deposits, was, however, rare; I only saw two cases, both in fractures of the femur; in both recovery followed secondary amputation. _Prognosis._--This depended almost entirely on the nature of the injury to the soft parts; given moderate injury to these, and the preservation of the wound from infection, scarcely any degree of injury of the bones precluded recovery, even if this were slow and prolonged. The existence of perforations scarcely increased to an important extent the gravity of a wound of the soft parts alone; in fact, this injury could not be regarded as more severe than an ordinary surgical osteotomy, putting the risks of infection of the wound under the special circumstances on one side. With regard to the functional results, these depended on the degree of comminution; when this was extreme, union was slow and for a time weak, and shortening was often considerable, but a fair result was as a rule obtained. Suppuration and osteo-myelitis were the dangerous features when they occurred; still, even in the presence of these, I never saw a fatal result in an upper extremity fracture, although in the lower extremity a considerable mortality followed fractures both of the leg and thigh, the deaths being most commonly from septicæmia, or from a combination of this with secondary hæmorrhage. _Treatment._--The general treatment was of a simple character. The perforations may be at once dismissed, since nothing more was needed than what has been already described under the heading of wounds of the soft parts. Again, with regard to the co-existence of vascular injury, or injury to the soft parts generally, the ordinary rules guiding us in civil practice were followed. The first point of importance, and needing consideration in the treatment of severely comminuted fractures, was as to whether in these it was better simply to try to obtain union of the wound with as little disturbance as possible, or to anæsthetise the patient and explore the wound, removing such fragments as were free or widely displaced. I think the answer to this question depends entirely on the nature of the external wounds. If these be of the small type forms, or if the exit aperture is, at any rate, of only moderate size, a strictly conservative attitude is the better when the risk of making an exploration under the circumstances is borne in mind, the more so as an exploration, to be safe and useful, ought to be done at once. If the exit wound is of the large or explosive type, on the other hand, there is no doubt that the best results are to be obtained by early exploration and the removal of all loose fragments. I saw several excellent results obtained in this way, even when the patients had to undergo the risk of transport shortly, in some cases the very next day, after the operation. The loose fragments are an immediate source of danger, and later may interfere with the healing of the fracture, even if suppuration does not occur. In all the cases that I saw the exit wound was dressed, but left freely open, and I do not think any attempt to close it should ever be made. The question of operative fixation rarely needs consideration; it occasionally happens, however, that oblique fractures, such as one mentioned on p. 166, are met with, in which screwing or wiring of the bone ends is advisable. What has been said above as to fractures, accompanied by loss of continuity, applies equally to cases of severe wedge-fracture, where many loose fragments exist. As to the disinfection of the limb, primary cleansing, mainly by soap and water, of course precedes the exploration, and when the latter has been carried out a second cleansing and disinfection, preferably with spirit and carbolic acid lotion, are imperative. Immobilisation is a more difficult problem. In practised hands plaster-of-Paris splints answer most requirements except in the case of the thigh; but the splints take time to apply and also to set firmly, and, as sometimes needing frequent removal, are not altogether suitable for Field hospital work. Of all the splints I saw in use, I think the best were wire splints, and the Dutch cane folding splints for the thigh and leg (figs. 56, 58); wire-gauze splints with steel at the margins (fig. 54), or strips of ordinary cardboard applied with some variety of adhesive bandage for the arm and forearm; and plain wooden of various lengths for any situation. A question of constant difficulty was that of frequency of dressing; in a Stationary or Base hospital this is not difficult, as the same surgeon has the patient continuously under his charge, and can readily decide as to the proper moment for the renewal of the dressing. When the patient is, however, being moved from the Field to the Stationary hospital, and thence to the Base, a constant succession of surgeons has the case in hand for short periods, the movements during transport disturb the fixity of the dressing, and, in consequence, dressings are apt to be far more frequent than is advisable. This question raises the larger one of the advisability of _any_ transport beyond what may be an actual necessity. There is only one answer to this. No fractures of the thigh or leg, and few of the arm, can be transported for any distance without material disadvantage. The risks attendant on disturbance of the fracture and tissue injury, septic infection as a result of slipping of the dressing and the impracticability of efficiently renewing it, far more than counterbalance any advantage to be gained from the superior comforts available at a Base hospital. For these reasons, if possible, all fractures of the arm, thigh, or leg should be kept at a Stationary hospital for a period of three or more weeks, and, as far as splints and appliances are concerned, these should be as numerous and complete as at a Base hospital. I have had a useful set made of aluminium. A word will be added later as to the splints suitable for different regions of the body. The necessity for _primary amputation_ chiefly depends on the nature of the injury to the soft parts, less commonly on the extent of the injury to the bones, and should be decided on exactly the same lines as in civil practice. So-called intermediate amputations are always to be avoided if possible; the results were consistently bad, and the operation should only be undertaken in cases of severe sepsis where little can be hoped from it, or for secondary hæmorrhage. When the operation could be tided over until the septic process had settled down and localised itself, secondary amputation gave very fair results. In either intermediate or secondary amputation for suppurating fractures, it was necessary to bear in mind the special likelihood of the existence of extensive osteo-myelitis. If this condition affected the upper fragment, an amputation was of little use unless the whole bone was removed, as septic infection continued and brought about a fatal issue, or a fresh amputation was required in order to obtain a stump that would heal. SPECIAL FRACTURES _Upper Extremity._--Fractures of the _scapula_ were not uncommon, but were mostly of the perforative variety; thus perforations both of the spine in longitudinal wounds of the back, and of the ala in perforating wounds of the thorax, were tolerably frequent. They possessed little practical interest; as a rule, the openings were not large, and the most unexpected feature was the small interference with the movements of the bone on the chest wall that resulted. It might be assumed that comminuted fragments would project into the muscles and cause both pain and interference with movement; but neither was the case. I saw grooving of the crest of the spine, but never happened to meet with a fracture of the acromion process. Many axillary tracks passed in the closest proximity to the coracoid, but this again I never saw separated. One practical point of importance with regard to the scapula was the frequency with which bullets lodged in the venter, or the firmly bound-down muscles of the supra- and infra-spinous fossæ. These retained bullets often gave rise to remarkably little trouble in this situation; thus I have a skiagram of a shrapnel bullet lying in the deepest part of the subscapular fossa, which did not inconvenience its possessor. [Illustration: FIG. 53. Head of Humerus, showing broken perforation. The roof forms a hinged covering to a groove.] Every variety of _fracture of the clavicle_ was met with, even perforation of the most compact portion of the shaft; comminuted, wedge, or notched fractures were, however, the more common, and were accompanied by the development of very large masses of provisional callus during the process of healing. An interesting skiagram is reproduced in plate III., which shows a compound form of injury to the clavicle. The bullet has passed obliquely beneath the acromial end, rising to perforate the posterior compact margin, and producing one of the diamond-shaped openings sometimes occurring in compact bone with the passage of bullets at a low rate of velocity. No case of perforation of the subclavian vein by comminuted fragments of the clavicle came under my notice. _Fractures of the humerus_ of every variety were common, and I think when the statistics of the campaign are published, it will be shown that the humerus was the most frequently injured individual bone in the whole body. I remember to have seen thirteen fractures of the shaft of the humerus in one pavilion alone at Wynberg after the battle of Paardeberg. Perforations of the upper articular extremity were common, and as a rule gave rise to wonderfully little trouble in the shoulder-joint. The outer aspect of the head of the humerus is a common situation for the production of a special form of broken canal or groove (fig. 53). The slope from the greater tuberosity to the shaft naturally favours the production of the injury in this position. I saw only one case in which a vertical fissure extended from a fracture of the shaft into the shoulder-joint; in this case the transverse solution of continuity was at the upper part of the middle third of the bone. Skiagram, plate IV., illustrates a well-marked stellate comminution of the shaft with large fragments. Plate V. shows extreme comminution with fragments blown out of the wound. Two plates, Nos. VI. and VIII., illustrate well the difference resulting from the oblique passage of a bullet at high and low rates of velocity respectively. In both cases good results were obtained; in the more severe the resultant mass of ensheathing callus was very large, temporarily interfered with flexion of the elbow-joint, and consolidation was very slow (see plate VII.). The patient was wounded at Belmont in November 1899, but he was able to row at the end of the summer of 1900, although very prolonged suppuration occurred, and the elbow movements became practically normal. Plate IX. illustrates a transverse track, the bullet having undergone considerable injury during its passage through the bone, as evidenced by the presence of fragments both of mantle and lead in the limb. This might be called an example of transverse fracture, and illustrates the nearest approach to one seen when the bone is struck fairly plumb. [Illustration: PLATE IV. Skiagram by H. CATLING Engraved and Printed by Bale and Danielsson, Ltd. (24) COMMINUTED FRACTURE OF THE HUMERUS Range about '300 yards.' The wound track took a directly antero-posterior course. Impact rectangular. The musculo-spiral nerve was completely divided. The plate affords a good example of the so-called 'butterfly' fracture. Two long doubly wedge-shaped lateral fragments, and pointed extremities to both main fragments, are shown. The fracture healed well, with the deposition of a large mass of provisional callus. The musculo-spiral nerve was united by suture some three months later.] Plate VIII. exhibits an oblique fracture of the lower part of the shaft produced by a bullet passing at a low rate of velocity. It does not widely differ from a perforation, and the illustration possesses some further interest as showing the deviation of a bullet likely to occur when a bone lies in its course. Although the velocity with which this bullet was travelling must have been very low, when the bone had been traversed the deviation in its course was slight. A few bony fragments from the compact tissue of the posterior surface of the humerus have been carried into the distal portion of the track. Fractures of the various prominences of the lower articular extremity were not uncommon, but deviated little from the types with which we are familiar in civil practice; the after results were good, both as to union and movement of the elbow. Explosive wounds of the soft parts were not infrequent in the arm, and fig. 48, p. 158, exhibits an extreme example. The humerus in respect of depth of covering, however, comes between the femur and the bones of the leg and forearm; hence such injuries were not so easily produced as in the latter segments of the limbs. In connection with the subject of fractures of this bone, one word must be added as to the occurrence of the most characteristic of its complications, musculo-spiral paralysis. This was frequent in every position of the fracture, and came on either immediately, or, at a subsequent period, as a result of callus irritation or pressure. Its frequency is only what would be expected when the nature of the fracture is considered, but the chief interest of the condition lay in the difficulty of certainly detecting it in the initial stages of the cases; this depended on the fact that in many of them the local shock to the limb was so severe that the function of the whole of the muscles was lowered, or in some cases, although the musculo-spiral was the nerve chiefly affected, the other large trunks had also suffered concussion or contusion. In consequence of this difficulty the actual localised paralysis often only became evident at the end of a week, or even more, when there was difficulty in deciding as to whether the paralysis was primary or due to secondary trouble. In the fracture illustrated by skiagram, plate IV., the nerve suffered complete division, and was united some three months later, improvement in the symptoms being very slow. The latter was a common experience, and although not unusual in civil practice, I think it is more marked in these injuries as a result of the more widespread character of the nerve lesion. [Illustration: PLATE V. Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson, Ltd. (25) COMMINUTED FRACTURE OF THE HUMERUS Range '50 yards.' Velocity extreme. Impact somewhat oblique. The bullet entered anteriorly about 3 inches above the elbow crease. The wound of exit was on the inner aspect of the arm and explosive in character; it still measured 4 inches by 2 inches three weeks after the injury was received. The wounds suppurated locally, but at the end of six weeks fair union of the bone had taken place and the wound of exit had contracted to a sinus. The musculo-spiral nerve was concussed, but not divided. The skiagram was taken three weeks after the reception of the injury. Comparison with plate IV. demonstrates the effect of high velocity in free comminution of the bone, the sharper radiation of the stellate lines of fracture, and the propulsion of bone fragments.] The _bones of the forearm_ were also often fractured. The principal peculiarity of these fractures was the common localisation of the injury to one bone, which is readily seen to be probable. Each bone offered some special features dependent on its structural character and anatomical position. In the case of the _ulna_, pure perforation of the olecranon process, without obvious evidence of implication of the elbow, was seen on several occasions. The other important feature with regard to this bone depends on its subcutaneous position, which accounted for the frequency with which highly developed explosive exit wounds were met with. One is figured in the general section (fig. 47, p. 156). This, however, is a very slight instance compared with what was often seen in the upper and middle thirds of the bone, where the lateral soft parts often protruded as a much larger tumour, the particular illustration being mainly designed to show the nature of the injury to the skin. The _radius_, as more deeply placed in the upper part of its course, was less often the seat of such well-marked explosive injuries; but when the lower end was struck this character was sometimes very striking: thus in a track passing antero-posteriorly through this bone, the whole lower end appeared shattered, all the tendons at the back of the wrist being implicated in the protruding mass, while the bone itself seemed shortened, so that the hand took up the position common in Colles's fracture. It was found impossible to place the bone in good position; nevertheless the patient retained his hand, which is still of use in writing. Plate X. is a good example of a high-velocity injury in which lateral contact with the radius has produced local comminution, some slight injury to the casing of the bullet, and the separation of a large wedge. The case from which this was taken also illustrated well one of the chief troubles of such fractures of the forearm; the degree of splintering resulted in the formation of a large mass of callus, which for a time rendered any degree of pronation and supination impossible. [Illustration: PLATE VI. Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson, Ltd. (26) COMMINUTED FRACTURE OF THE HUMERUS Range '250 yards.' Impact oblique. Wound of entry 1 inch below the insertion of the deltoid; exit, on inner aspect of arm at a slightly lower level. The bullet probably struck the bone laterally, and drove out the central fragment. Prolonged suppuration resulted, but the humerus healed well, and good movement of the elbow was preserved. The effect of oblique impact together with high velocity is well illustrated. Had the resistance been greater, as in the case of the femur, a nearer resemblance to the effect seen in plate XV. would have been the result.] Of _fractures of the hand_ I have little to say. In the case of the _carpus_, the slight degree of resistance offered by the bones rendered injuries of an explosive character rare. I never saw one. Fractures of the _metacarpus_, on the other hand, presented exactly the opposite features. The density of these small bones was well illustrated by the frequency with which the bullet suffered injury, even amounting to fragmentation, and the great comminution they themselves suffered. The breaking up of the bullet in these fractures was a curious feature, which may perhaps be explained by the tendency of the distal part of the limb to be driven in the course of the bullet, with the result of somewhat lengthening the period of contact of the projectile, or more probably by somewhat frequently occurring irregular impact. Plate XI. is a good example of an injury of this nature of moderate severity. The soft parts suffered much in these injuries, the tendons were torn and lacerated at the moment, and were very apt to acquire more or less permanent adhesion. This latter condition was sometimes to be improved by the removal of bone fragments, and I have freed tendons from actual clefts in the bones where they had been carried in by the bullet. In some cases very great deformity of the digits, due to shortening, developed, even when no fragments were removed beyond those blown away by the bullet. One form of injury of some interest was multiple fracture of the phalanges produced by a bullet travelling in a course parallel to the length of the rifle when pointed by the patient. Occasionally several digits were lost. _Treatment of fractures of the upper extremity._--The general lines of this have already been foreshadowed in the general section, the remarks as to transport being applicable to all serious fractures of the shaft of the humerus, and this is the only one of the bones of the upper extremity on which anything special need be said, as the treatment of all the other fractures exactly coincides with that of ordinary civil practice. [Illustration: PLATE VII. Engraved and Printed by Bale and Danielsson, Ltd. (26_a_) CONDITION OF THE SAME FRACTURE SHOWN IN PLATE VI., A YEAR AFTER ITS PRODUCTION The ensheathing callus is still very abundant, but less so than at an earlier date. No trouble with the musculo-spiral nerve was noted, but residual abscesses occurred from time to time in connection with the fracture.] [Illustration: FIG. 54.--German Wire Gauze Splint on steel wire foundation. (German Ambulance, Heilbron)] The treatment of wounds should be on the lines already laid down: thorough cleansing, and then an attempt to seal. In severely comminuted fractures, however, the exit wound may be of very large size, and then frequent dressings are necessary. Loose fragments, by which those freed from their periosteal connections are meant, need removal. The question which most interested me was the best method of fixation. This needs to be sufficient to effect immobility, but on the other hand in many cases the weight of the arm as a means of extension is very valuable. Some of the most successfully treated cases that I saw were fixed by means of simple strips of pasteboard, applied moist, and fixed with an adhesive bandage. Ordinary book-muslin bandages are as good as anything for this purpose, as they can be reinforced by a stronger form outside them. Where necessary, an angular piece of cardboard can be applied on the inner aspect, or a wooden angular splint may be substituted, if it is at hand; but in this case most of the advantage of the weight of the arm as a means of extension is lost. The cardboard cases possess the great advantage of being readily cut off and reapplied much as is done with plaster of Paris. During the period in which dressing may be necessary I believe this form of splint is as good as can be got for use in Field hospitals, the only point needing care being to ensure that the bandaging is not too tight. It is much more reliable than are ordinary splints if transport is unavoidable, and is much lighter and less irksome to the patient. With such strips of cardboard, a few of the gauze splints (fig. 54), and a few angular and wooden splints, I believe a Field hospital is fully equipped for the treatment of any fractures of the upper extremity. [Illustration: PLATE VIII. Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson, Ltd. (27) OBLIQUE FRACTURE OF THE HUMERUS OF THE NATURE OF A PERFORATION Range more than '1,000 yards.' The distance was probably much greater, as the bullet was retained and undeformed, and the comminution of the bone was very slight. The wound of entry was just below the elbow. The bullet has cut its way through the inner half of the humerus, producing little comminution and mere solution of continuity of the bone without displacement] _Fractures of the pelvis._--These, as a rule, were of so slight a nature as to form a very insignificant part of the entire injury with which they were associated, or when uncomplicated they were of little more importance than simple wounds of the soft parts. The very great majority were of the simple perforating type. I had the opportunity of examining three at the brim of the pelvis, these all passing in a downward direction. The openings were of about the same calibre as the bullet, and at their entrance was a small amount of bone dust such as would be found at the entry hole of a gimlet. It was these that made me consider the possibility of the rifle grooves having some part in the ease with which certain perforations are made. Of a large number of cases in which bullets traversed the ilium, the openings in the bone, as a rule, were with difficulty palpated. I must say that I was astonished that I never met with an instance of an extensive stellate fracture in the case of the ilium. Such may have occurred in some of the cases fatal on the field or shortly afterwards, but I never came across one in the hospital. It says much for the combined density and toughness of the human pelvis. Comminuted fractures were, however, occasionally met with when the bullet passed in a track parallel to the plane of the bone. One such of an unusual character has already been mentioned on p. 171. A still more interesting form, and one highly characteristic of flat bone injuries, is shown in fig. 55. The patient, a man wounded at Modder River, was struck at a range of 300 to 400 yards. The bullet entered over about the centre of the ilium and emerged in the anterior abdominal wall about 2 inches above the anterior-superior spine. As there was some doubt as to penetration of the abdomen, and as the exit wound was of considerable size, the wound was explored, an anæsthetic having been given. A clean-cut track in the bone was discovered which allowed the middle finger to be placed in it. There was little splintering of either inner or outer table of the bone beyond the width of the track, but plates of each table adhered on the one side to the origin of the gluteus medius, and on the other to the iliacus, the latter muscle being somewhat widely separated from the venter ilii by effused blood. There was no perforation of the abdominal cavity. [Illustration: PLATE IX. Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson, Ltd. (28) LOCALISED COMMINUTED FRACTURE OF THE HUMERUS Range '100 yards.' The entry and exit wounds were on the front and back aspects of the arm, about 3 inches above the elbow. Fragmentation of the mantle of the bullet has occurred. It will be noted that the fragments are lodged in both the proximal and distal segments of the track. This may indicate that the bullet was damaged prior to entry, or the recoil of fragments. I incline to the latter view. The skiagram was taken a fortnight after the injury. The large median fragment carried forwards, and the small degree of comminution, suggest the decrease of resistance and prolongation of impact by carriage back of the arm when struck. The fracture is one of the nearest approaches to a transverse cleft that I met with. The plate may well be compared with No. XII., where the effect of increased resistance in augmenting the degree of comminution is seen.] Lesser degrees of the same kind of injury amounting to grooving of the surface or notching of the crest of the ilium were not uncommon, and the occasional large character of exit openings in buttock wounds pointed to contact of travelling bullets with other parts of the external pelvic wall. [Illustration: FIG. 55.--Clean Gutter Fracture of the Ilium (range placed by patient at 300 yards. Highland Brigade, Magersfontein). The gutter was clean cut, and admitted the forefinger. The inner and outer tables of the bone were in part blown out of a large irregularly circular exit opening about 1-1/2 in. above the crest of the ilium. The cancellous tissue was probably entirely blown out. Plates of the outer and inner tables still remained connected by their periosteum to the deep aspects of the iliacus and gluteus medius muscles. The peritoneal cavity was not opened. The patient did well. Compare with the gutter fractures of the skull shown in figs. 64, 66.] Certain portions of the pelvis were subject to more severe comminution; thus in one case in which the bladder was wounded, a very much comminuted fracture of the horizontal ramus of the pubes was produced by a bullet which subsequently lodged in the thigh behind the femoral vessels. In this case the track was so oblique as to have necessitated almost pure lateral impact on the part of the bullet; hence the form of injury was nearly allied to the comminutions of the ilium already described. [Illustration: PLATE X. Skiagram by H. CATLING Engraved and Printed by Bale and Danielsson, Ltd (29) Wedge-shaped Fracture of the Radius Range 'a few yards.' The officer shot the man, his assailant, with a revolver. The entry wound was on the posterior aspect of the forearm at the junction of the middle and lower thirds. The exit wound was on the anterior aspect of the forearm, 1 inch below the elbow crease, and of moderate size. Some fine fragmentation of the mantle of the bullet is indicated, and very fine comminution of the bone. The fracture healed well, but the resulting mass of callus at the end of three months prevented any movements of pronation or supination.] I never observed a fracture of the floor of the acetabulum by a bullet which had entered from the back of the pelvis, although tracks entering by the great sciatic notch were not infrequent. I saw one case in which a bullet which traversed the upper part of the shoulder and emerged at the axilla entered a second time an inch behind and above the anterior superior spine, and split off a layer of the outer table of the ilium of the extent of two square inches, which involved the upper portion of the rim of the acetabulum. No displacement upwards of the femur resulted; but external rotation was accompanied by crepitus. The wound suppurated, and some general infection resulted, but six weeks later there was no evidence of fluid in the hip-joint, the limb was adducted and slightly rotated outwards, and some movement in each direction could be made without causing any great amount of pain. I can say nothing of the further course of this case, as I neglected to take the patient's name. I saw one or two instances of perforation of the sacrum. One is mentioned in the chapter on injuries to the abdomen, in which a central puncture at the level of the fourth vertebra was accompanied by temporary incontinence of fæces. Fractures of the _femur_ were fairly numerous and formed one of the most serious classes of case we had to treat, as well as one of the most fertile sources of mortality in the Base hospitals. In spite of the last observation, however, it is probable that the results in this campaign will be far better than in any previous war, both as to the smaller proportion in which amputation was needed and as to recovery. [Illustration: PLATE XI. Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson, Ltd. (30) COMMINUTED FRACTURE OF THE SECOND METACARPAL BONE Large fragments of the mantle of the bullet. Fragmentation of the bullet was comparatively common when the metacarpal bones were struck, also free comminution of a somewhat coarser variety than that seen when bones offering greater resistance were struck. This may be a result of the more frequent lateral impact of the bullet on these small bones.] In spite of a considerable experience, I never saw a case of perforation of either the head or neck of the thigh bone. I saw numerous tracks emerging at the side of the femoral vessels and entering at the buttock or vice versa, but never one accompanied either by effusion into the hip-joint or impairment of movement. Considering the regularity with which hæmarthrosis occurred when the other joints were crossed, and also the nature of the compact tissue of the neck of the femur, which must have ensured some splintering, I do not think I can have overlooked an injury of this nature. No doubt also the escape of the neck of the bone was explained in some of the cases by the fact that the injuries were received while the hip-joint was in a position of flexion, the bullet passing over the neck of the femur. In two cases of extensive comminution of the upper third of the femur that I saw, the fissures stopped short at the inter-trochanteric line anteriorly, but in one of them a large angular fragment was torn out of the posterior surface of the neck. Excepting transverse fracture every form was met with in the shaft, although I saw only two instances of perforation. One has been already alluded to and was situated in the broadening portion of the lower third, the bullet taking an antero-posterior course. The second is seen in plate XVII. Plate XII. shows an instance of extreme comminution of the upper third accompanied by the presence of two typical elongated fragments. The course taken by the bullet was almost directly antero-posterior, and the wounds were of moderate size even in the case of the exit one. This seems to preclude the possibility of the injury having been produced by a ricochet bullet, while the fact of perforation and escape of the bullet in spite of the serious damage suffered by the mantle points to the injury having been produced at a short range of fire. The patient himself owns to being quite unable to give any estimate of the distance. Although no suppuration occurred, this fracture was very slow in consolidating, and the free comminution with consequent inaccurate apposition led to the development of four inches shortening of the limb. The skiagram was taken about six weeks after the occurrence of the injury, a few days after I first saw the patient; I have, however, had the opportunity of seeing a second skiagram taken some four months later. This is of considerable interest, as throwing light on the mode of union of such fractures. The two elongated fragments in the later skiagram are widened to three times their original breadth, and form buttresses on either side of the point of union, while the irregular ends of the shaft are rounded off, and the mass of fine fragments behind is consolidated. Beyond this the second skiagram shows that the upper fragment, apparently intact in the first, was really split longitudinally, and therefore was far less useful as a point of support than might have been assumed from the earlier skiagram, plate XIII. The case illustrates well the chief difficulty in the treatment of such fractures: that of maintaining the fragments in line, since absolutely no help is received from the apposition of the two ends, and artificial traction alone must be relied upon. [Illustration: PLATE XII. Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson, Ltd. (31) HIGHLY COMMINUTED FRACTURE OF THE UPPER THIRD OF THE SHAFT OF THE FEMUR Range 'short.' Impact fairly direct. The wounds were of moderate size and at nearly the same level. The exit wound near the buttock fold was of moderate size, and presented no special features. Considerable fragmentation of the bullet occurred. The comminution of the bone is very fine, suggesting high velocity, and great resistance by the bone. The skiagram was taken five weeks after the injury was received, and at that time no union had occurred. Reference to plate XIII. will explain more fully the difficulty experienced in maintaining this fracture in position. The upper fragment is seen to be split into fragments, beyond the separation of the long splinter on the inner side; hence no aid was to be obtained from the apposition of the ends. About 2 inches of the shaft were actually pulverised; the fine fragments seen in a mass to the inner side of the bone in the exit portion of the back, eventually formed a large mass of callus, and the fracture united, with considerable shortening.] Plate XIV. offers a good contrast; the fracture here presents a typical stellate form, and a good result without shortening was readily obtained. I assume that the difference in character of these two fractures depended mainly on the rate of velocity with which the bullet was travelling, since it passed fairly directly across the limb in each. I think it is clear, however, that the bullet struck the femur rather nearer the centre of the width of the shaft and therefore more directly, in the more severe injury. This brings me to the question of explosive exit wounds in the thigh. In spite of the great tendency to comminution of the shaft, these were rare in a severe form. This depended simply on the depth and thickness of the coverings of the bone, and, as already mentioned, although the skin openings were often comparatively small, a large cavity or area of destroyed soft tissues may be contained within the limb. I do not think I ever saw an exit wound in the thigh exceeding 1-1/2 inch in diameter. The oblique fracture illustrated by plate XVI. has been already referred to, and the influence of the weight and movement of the trunk on its production has been considered. Plate XV. illustrates an obliquely comminuted fracture of another character. The bullet has here been stripped of its mantle, which has undergone fragmentation, but the leaden core is little altered in shape. This is of much interest, since it shows that the bullet struck the bone by its side. The effect of such lateral impact on the part of the projectile is well shown: there is great bone comminution of a less regular character than usual, and the bullet is retained. Retention in this case was probably not a result of low velocity of flight, but of the increased resistance offered by the broad area of bone struck, and the check exerted on the axial rotation of the bullet by the lateral contact. [Illustration: PLATE XIII. Engraved and Printed by Bale and Danielsson, Ltd. (31_a_) THE FRACTURE SHOWN IN PLATE XII., SIX MONTHS AFTER RECEPTION OF THE INJURY The amount of callus furnished around the loose fragments is very striking. The upper end of the bone is shown to have been divided into at least two fragments, hence one of the difficulties of maintaining the ends in apposition. The stoppage of the fissuring short of the epiphysis is characteristic.] Slighter injuries to the femur in which the shaft was chipped or grooved without loss of continuity were not uncommon, and showed well the capacity of the bone to withstand the lateral shock transmitted by small bullets. Two figures inserted in the chapter on wounds in general (figs. 22, 23, pp. 61, 62) are of cases in which, from the appearance of the wound of exit, the bullet probably underwent deformation, or was so deflected as to escape on a considerably altered axis. Beyond the nature of the exit wound in the case depicted in fig. 22, some thickening beneath the femoral vessels denoted bone injury, but unfortunately no skiagram was taken. I saw no case in which a transverse fracture of the shaft accompanied such injuries, but am under the impression that, if they had been produced by bullets of greater volume and weight, transverse solution of continuity would have been more common. In point of fact, no case of pure transverse fracture of the femur ever came under my notice. The diagram depicted in fig. 51, p. 164, is from a sketch made of the lower end of a femur in which a severely comminuted fracture followed by suppuration necessitated an amputation of the thigh, performed by Major Lougheed, R.A.M.C. It is inserted as an illustration of the tendency of the fissures to stop short above the actual articular extremities of the bones. In this case the comminution was extreme and accompanied by the usual long lateral fragments, one of which measured five inches in length and might well have extended into the knee-joint had that been an ordinary occurrence. Perforations of the lower extremity of the bone were very common. These were sometimes transverse and limited to the articular extremity itself, or the same limitation occurred to the antero-posterior tracks. These were the slightest forms of injury, putting on one side incomplete tunnels and grooves on the surface of the bone. With regard to the latter, however, when they invaded the joint cavity the injury was liable to be more severe than a complete perforation, in consequence of the projection of comminuted fragments into the joint cavity near the line of reflection of the synovial capsule and ulterior interference with freedom of movement. [Illustration: FIG. 55_a_.--Diagram of 'Butterfly' type.] [Illustration: PLATE XIV. Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson Ltd. (32) TYPICAL STELLATE (BUTTERFLY) COMMINUTED FRACTURE OF THE FEMUR Range 'short.' Wounds small, impact direct, very little fine comminution. The bone united without shortening of the limb.] Other tracks took a direction of longitudinal obliquity, and then implicated both epiphysis and diaphysis. Fig. 52, p. 169, shows an example, and also the peculiarity likely to be assumed by the exit aperture in the bone, especially if the bullet was travelling at a low rate of velocity, a considerable plate of the compact bone being driven out. In some cases these oblique tracks involved both femur and tibia. They will be referred to again under the heading of injuries to the joints, and some remarks will also be found there regarding the synovial effusion so often occurring into the knee-joint in cases of fracture of the shaft of the bone. It may be of interest to insert here a few remarks as to the clinical characteristics of fractures of the femur. First with regard to the primary signs and symptoms. A very considerable degree of general or constitutional shock usually accompanied them, and this was perhaps more constant than in the case of any other injury in the body. This was, moreover, no doubt increased by the unfavourable conditions in which patients on the field of battle are situated in regard to transport. When the patients were brought into hospital some delay in the primary treatment was often necessary until reaction took place. Local shock to the part was also a prominent feature. Abnormal mobility was very free in the badly comminuted cases. Crepitus was often loose, and of 'the bag of bone' variety. The result of local shock and consequent flaccidity of the muscles was to reduce the development of primary shortening; in some cases of severe comminution this was practically nil during the first day or two, when, with return of tone in the muscles, it sometimes became very considerable. Swelling of the limb was often very great, and vascular injury definitely far more common than in the fractures of civil practice, in consequence, no doubt, not only of the number and sharpness of the fragments, but also of the force with which they were driven into the surrounding tissues. The exit segment of the track was out of all proportion in size to the entry, as a result of the propulsion of bone fragments through it. This often made the closure of the exit wound a very protracted event, the track continuing to discharge a small quantity of bloody serum and fragments of necrosed tissue for many weeks. [Illustration: PLATE XV. Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson, Ltd. (33) COMMINUTED FRACTURE OF THE FEMUR Range 'short.' Normal entry wound of slightly oval form. Oblique lateral impact on the part of the bullet, the mantle of which burst into numerous fragments. The bullet is seen to the inner side of the shaft, almost devoid of its mantle, and little deformed at the tip. The comminution of the upper portion of the fracture is very fine; the bullet has merely cut its way down the lower portion, and one or two long fragments are separated. The skiagram shows well the result of lateral impact by the side of the bullet. Compare this plate with No. VI. as illustrating lesser resistance, and No. VIII. as illustrating the effect of lower velocity.] In a large proportion of the cases which were transported for any distance suppuration occurred; this must have been the case in at least 60 per cent. of the fractures. Suppuration was of the character already described in the general section, affecting particularly the bone itself, and accompanied by very marked signs of general infection. _Prognosis in fractures of the femur._--As regards mortality fractures in the upper third of the bone proved one of the most formidable injuries which came under treatment. Suppuration was common, at least 60 per cent. of the wounds becoming infected. This depended on several reasons, often inseparable from the injuries, or from their treatment in Field hospitals: such as (1) the exit wound being situated in the dangerous region of the thigh; (2) ineffective dressing and fixation; (3) the impossibility of ensuring primary cleansing and removal of detached fragments of bone; (4) the necessity of the early transport of patients to the Stationary or Base hospitals, often for great distances; (5) the comparatively long period that often had to elapse before the opportunity of doing the first efficient dressing arrived. Fractures in the middle and lower thirds of the bone were more easy to treat successfully, but these also added to the list both of amputations and fatalities. Punctured fractures of the lower articular extremity were usually of little importance, as they progressed without exception, as far as my experience went, favourably. I can give no idea of the general results obtained during the whole campaign, but I am able to state the results of the fractures of the shaft treated at No. 1 General Hospital during my stay in South Africa. Thirty-two cases of fracture of the shaft of the bone came under treatment, and of these 6 or 18.7 per cent. needed amputation, and of the whole number 5 or 15.6 per cent. died. To emphasise the satisfactory nature of these figures I need only quote the results attained in the American War of the Rebellion; mortality in upper third, 46 per cent.; middle third, 40.6 per cent.; lower third, 38.2 per cent. [Illustration: PLATE XVI. Engraved and Printed by Bale and Danielsson, Ltd. (34) OBLIQUE FRACTURE OF THE SHAFT OF THE FEMUR Range '300 to 400 yards.' Aperture of entry just above the centre of the outer aspect of the thigh. Exit, about 2 inches lower, at the junction of the inner and posterior aspects. The bullet was retained just within the wound, and when removed the mantle fell off in two parts. The leaden core was mushroomed. The bullet had passed through another soldier previous to entering the patient's thigh. Only two small fragments of the mantle were retained, as seen in the skiagram. These were in the substance of the great sciatic nerve, and were subsequently removed by Sir Thomas Smith. It is difficult to determine how the bone was struck; reference to plate XXI. would suggest that the shaft may have been perforated, but no evidence of this remains in the skiagram taken, which was five months later. The patient was standing at the moment of reception of the injury, and the obliquity of the fracture no doubt depended on his fall and the resulting influence of the weight of the body. The length of the fracture cleft was 9 inches.] I need hardly dwell upon the difference between the nature of the injuries received in the American War of the Rebellion and in the present campaign, as in the former the old large bullets were employed, and shell injuries are possibly included; but I ought to add in this relation, that the numbers quoted from No. 1 General Hospital included, to my knowledge, at least three severe Martini-Henry wounds. The first element for a favourable prognosis is a small wound, and opportunity for an efficient primary treatment of the same; the second the absence of necessity for transport of the patient. With regard to the second of these requirements, we were unfortunately situated in South Africa, and the majority of the cases which did badly were moved during the first few days and for a distance of between five and six hundred miles. On the other hand, as a rule, the external wounds were small. As to functional result, the fractures did well. I think an average of an inch and a half would well cover the shortening, and in many the length was little altered. Considering the serious nature of many of these fractures, this was good. _Treatment._--In all punctured fractures of the lower extremity, dressing of the wounds like uncomplicated ones and a short period of immobilisation were all that was necessary. In oblique fractures, and those with slight comminution, closure of the wound by dressings, after it had been carefully cleansed, was all that was necessary prior to applying the splints for immobilisation. [Illustration: PLATE XVII Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson, Ltd. (35) PERFORATION OF THE SHAFT OF THE FEMUR. FLAP OF BONE RAISED AT THE APERTURE OF EXIT IN THE POPLITEAL SURFACE OF THE SHAFT. Range 'over 1,000 yards.' Compare with fig. 52, p. 169.] In the highly comminuted fractures a more radical treatment was indicated, especially if the exit wound was large. In these, after careful preliminary cleansing of the limb, the wounds, especially the exit aperture, needed exploration and, if necessary, enlargement, and all free splinters needed removal. If interference with the entry wound could be avoided, this was always preferable, as it was rare for this not to heal by primary union unless free suppuration occurred. Under Field hospital conditions I think the exit wound should never be sutured, whatever its situation; and in the present campaign, where carbolic acid lotion was freely used, this step was manifestly inadvisable, in view of the abundant serous discharge always to be expected when this disinfectant has been employed. Except in cases manifestly infected at the time of exploration, the use of drainage tubes or plugs is not to be recommended. I would point out also that in the majority of cases it is quite hopeless to attempt to make the entry wound the safety-valve for drainage, as its natural tendency, even if enlarged, is to heal, while the condition of the tissues in the exit segment of the track usually renders primary union an impossibility. The wound having been dealt with, the next indications were for the reduction of deformity, immobilisation of the limb, and the provision of a proper degree of extension. As to the reduction of the fracture, this was always a matter of ease, needing only slight axis traction. The provision of efficient means of extension and immobilisation was a very different matter. These questions had to be considered under two sets of conditions: (1) when it was possible to keep the patient at rest in the hospital he was first deposited in; (2) when it was necessary for him to be transported for a considerable distance, probably not less than 500 miles. When transport is a necessity, the best method of immobilisation is the application of breeches of plaster of Paris, and a long outside splint. The latter we often had excellently made on emergency by the Ordnance Department or the Royal Engineers. A perineal band is the only form of extension possible under these circumstances. The Dutch ambulances were provided with a very excellent emergency splint for cases of fractured thigh, which is illustrated in fig. 56. I think something of this kind should be carried in one of the ambulances going on to every field of battle, as being far more suitable than a long outside splint for hasty and inaccurate application. This splint, fixed with some kind of firm bandage, is an excellent temporary one for use during transport. [Illustration: PLATE XVIII. Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson Ltd. (36) OBLIQUELY TRANSVERSE FRACTURE OF THE PATELLA Range 'short.' The entry and exit wounds were small, and a distinct grooving from loss of substance of the bone was palpable superficial to the actual cleft of the fracture.] [Illustration: FIG. 56.--Dutch Cane Field Emergency Splint for Thigh or Lower Extremity. (Dutch Ambulance, Winberg)] In cases which can be treated at a Stationary hospital near at hand, a long outside splint supplemented by plaster breeches, and a well-applied American extension, is a very good method of treatment, the only point to bear in mind being frequent examination of the position of the limb to ensure the extension being efficient. As already mentioned, the shortening in the primary stages is often slight and easily combated, but in many of these cases if examined in a few days the limbs are found to have shortened considerably, principally as a result of recovery of tone by the muscles, and the absence of any help from the resting of the two fragments end to end. The weight, therefore, has often to be progressively increased and the fracture readjusted if necessary. Although this method of treatment is satisfactory in cases with a small wound, it is very troublesome to carry out, even when a bracket is inserted opposite the wound, when frequent dressing is necessary, as is generally at first the case when the wounds are large. For this purpose a much more satisfactory method is the use of Hodgen's splint. This allows of automatic adjustment of the degree of extension, and the dressing of the wound without interference with the position of the fracture. A continuous many-tailed bag is preferable to the strips usually employed for the suspension of the limb, as more easily adjustable and as offering a more even support to the limb. [Illustration: PLATE XIX. Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson Ltd. (37) OBLIQUE COMMINUTED FRACTURE OF THE TIBIA Range '600 yards.' The entrance wound was large and the exit also. The fracture may have been caused by a Mannlicher (8 mm.) soft-nosed bullet, or possibly a ricochet. The fragmentation is somewhat coarse at the periphery, but very fine in the track of the bullet. Several fragments of the mantle are visible. The fracture affords a good example of obliquity due to cutting by the bullet, and contrasts well with those due to rectangular impact such as are shown in plates IV. and XIV.] While at Orange River, in conjunction with Major Knaggs, R.A.M.C., and Mr. Langmore, we treated several cases of fracture of the shaft of the femur by this method. The splints were made for us by the Ordnance Department, while the Royal Engineers erected a kind of gallows for us down the centre of a commissariat marquee in order to avoid the risk of using the tent poles for suspension. The patients were then ranged on each side of the tent in two rows so that the pull of the two sets of limbs opposed each other on the gallows from which they were suspended. Although these patients had to lie on the ground, they were really comfortable compared with those treated with long outside splints, and the results obtained were very good: in three cases which I had the opportunity of measuring later the bones were in good position and the shortening was less than one inch. I have no doubt whatever that Hodgen's splint is by far the best method of treating all cases of fractured thigh in the Stationary field hospitals; and, more than this, I believe it is the only practicable and efficient one. It can be applied without the use of an anæsthetic without causing undue suffering to the patient, it allows of ready change of the dressing, it is comfortable and permits considerable range of movement on the part of the patient, it is as efficient with patients lying on the ground as in a bed, it keeps the limb in good position and allows of constant inspection on this point, and it is the only method which provides satisfactory extension without constant readjustment. [Illustration: PLATE XX. Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson Ltd. (38) TRANSVERSE FRACTURE OF THE TIBIA, COMMINUTED FRACTURE OF THE FIBULA Range '300 yards.' Wound of soft parts nearly transverse, entry on tibial aspect. The bullet crossed and grooved the posterior aspect of the tibia, but struck the fibula full. This is the only instance of a transverse cleft which came under my notice. The wound suppurated, and a number of fragments of the fibula needed removal; hence the amount of callus present.] Cases in which operative fixation is indicated are rare, but a few oblique fractures may be treated with advantage in this manner if the conditions surrounding the patient admit of it. Screwing is generally preferable to wiring. Lastly, we come to the cases in which primary amputation is necessary. I may say at once that I saw no case of wound from a bullet of small calibre in which this was indicated, and only one shell injury in which it was performed. I believe with small bullets that injury to the main blood-vessels is almost the only indication which is likely to be met with, and this by no means always indicates an amputation. First of all the question arises as to whether the wound in the vessel is caused by a bone fragment or by the bullet itself; reference to the chapter on blood-vessels would seem to prove that a bullet wound is by no means a necessary indication for amputation. Given favourable conditions, it might be treated locally by ligature at the time, while if hæmorrhage is not proceeding, developments should be awaited before proceeding to amputation. In the case of bone fragment punctures, secondary hæmorrhage is a more likely indication for amputation than primary. Broadly, it may be laid down that very extensive injury to the soft parts is the only indication for primary amputation beyond primary hæmorrhage, and it may be added that the condition is rare with wounds from small-calibre bullets. If a primary amputation is necessary the observations as to the transport of fractured thighs are equally applicable. I never saw a primary amputation do well that was moved during the first week; sloughing of flaps or hæmorrhage followed as a rule, and often death. Intermediate amputations were indicated in cases of septic infection and those of hæmorrhage; they seldom did well, and should be avoided if possible. Secondary amputations for sepsis or hæmorrhage were attended by fair results, but I can give no statistics. Unless extensive osteo-myelitis is evident, or very widespread cellulitis of the limb exists, I am strongly of opinion that the amputations when the fractures are above the middle of the thigh should be through the fracture, and not at the hip-joint, even if a subsequent secondary operation is risked. [Illustration: PLATE XXI. Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson, Ltd. (39) PERFORATION OF THE SHAFT OF THE TIBIA, AND INCOMPLETE OBLIQUE FISSURE EXTENDING FROM THE LOWER PART OF THE OPENING TO THE CREST OF THE BONE. Range medium. Entry and exit wounds at same level. The patient was standing when struck, and fell backwards, his rifle falling at the same time and striking the shin. The fibula is intact. The perforation indicated by the well-marked translucent spot is small. The forking of the lower extremity of the cleft suggests the starting of the fissure from above. The fissure comes to the surface at the seat of election, but its position may possibly have been determined by the blow from the falling rifle. The backward fall of the patient clearly explains the mechanism of production of the fissure, and throws light on the production of an oblique fracture such as shown in plate XVI.] _Fractures of the patella._--Punctured fractures of the patella were common with direct impact of the bullet; these were often difficult to palpate, and were only to be certainly diagnosed by attention to the direction of the track, and the development of hæmarthrosis. I saw at least three or four in which the bullet, in addition to traversing the knee-joint, injured the popliteal vessels. I have notes of one case in which a bullet traversed the soft parts from above downwards and scored a vertical groove on the surface of the patella; this was readily palpable, but produced no solution of continuity. In several cases the margin of the patella was notched by a passing bullet. I never saw a case of stellate fracture, and by this my experience in the case of the ilium was confirmed. On two occasions I saw pure transverse fractures of the bone; in each the wound was produced by a Lee-Metford bullet. This is of some interest as denoting that the greater volume and weight, in conjunction with the blunter tip, of the Lee-Metford may produce more severe injury to the bones than the Mauser. I believe this to be the case, given an equal degree of velocity on the part of the bullet at the moment of impact; but it is probable that the position of the patella with regard to the condyles of the femur when struck is of far greater importance in relation to the production of transverse fractures. The skiagram represented in plate XVIII. shows an obliquely transverse fracture, which in this instance resulted from a crossing bullet, which grooved the surface of the bone. With regard to the two cases of transverse fracture above referred to, I may add that one occurred in a youth under twenty, and a good result was obtained by treatment with splints, and later by massage. In the second the patient was a man over fifty, who had received other injuries. The wound over the patella healed and some union had occurred, when the patient fell and burst both the bone union and the skin cicatrix. Secondary suppuration of the knee-joint, necessitating an amputation of the thigh, followed, but the patient made a good recovery. The third case also did well. [Illustration: PLATE XXII. Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson, Ltd. (40) NOTCH FRACTURE OF THE CREST OF THE TIBIA Range 'short.' The raising of the margins of the notch suggests a perforation. Compare with figs. 51 and 57 in the text.] The treatment of these injuries differed in no way from that adopted in civil practice, given satisfactory surroundings. Suture might be indicated in some cases of transverse fracture, but this would only be necessary if the fragments were widely separated. The punctured fractures needed treatment as for simple wounds, combined with a short period of rest and pressure for the condition of hæmarthrosis. It was important not to prolong the period of rest beyond a week or ten days if the effusion was slight, in view of possible ulterior interference with range of movement in the knee-joint. _Fractures of the tibia._--Some remarks have already been made regarding fractures of the head of the tibia, and the importance of the overhanging prominent margins in the production of somewhat irregular injuries (p. 170). Putting these peculiarities on one side, the cancellous ends are subject to the type forms of injury; thus perforations either of the head of the bone or the malleolus were common injuries. The fractures of the shaft also deviated from the type in so far as the broad flat surfaces in the upper two thirds of the bone rendered it especially liable to the results of lateral impact, and to the production of the extreme wedge-shaped types of fracture. Plate XXII. illustrates the different result of a bullet striking the dense and strong spine at a low rate of velocity, a notch only resulting. If, on the other hand, the lateral surfaces were struck, a wedge with the base corresponding to the posterior surface was the most common injury, the spine in many cases remaining intact and maintaining the continuity of the bone. Wedge-shaped fractures of this bone were apt to show multiple secondary wave fissures concentric with the main line, and consequently free comminution. I saw several examples, the loose fragments being remarkably numerous. Plate XIX. is an example of an oblique fracture produced by a bullet which has ploughed across the bone, displacing large fragments anteriorly, but finely comminuting the bone in its course, and leaving small fragments of the mantle on its way. Plate XX. is an example of the rare condition of transverse fracture. [Illustration: PLATE XXIII Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson, Ltd. (41) SPURIOUS PERFORATION OF THE FIBULA Moderate range, 'about 1,000 yards.' The injury was caused by an 8 mm. bullet, which entered base foremost and lodged in the calf. The fracture is really an incomplete stellate form, two well-marked transverse fissures extending from the point struck. The position of the bullet suggests its entry into the limb base foremost, and as it is retained low velocity may be assumed.] This fracture was produced by a bullet travelling at a high rate of velocity, which struck the posterior surface of the tibia, and caused a grooving, accompanied by a horizontal fissure through the whole thickness of the bone; later it struck the fibula more directly, and produced an ordinary comminuted fracture two inches above the malleolus. Perforations of the shaft were far more common than in the case of the femur, and I saw them in every part of the length of the bone (plate XXI.). Fig. 57 illustrates a form of peculiar interest as showing the gradual transition of the tunnel to the groove, and also as bringing fractures of the long bones into line with such fractures of the flat bones of the skull as are depicted in fig. 68. [Illustration: FIG. 57.--(42) Perforation of lower third of Tibia, showing lifting and fissuring of the compact roof of the tunnel. Compare with fig. 68, p. 259, of a fracture of the cranial vault.] _Fractures of the fibula_ offered no special features of importance. Any form might occur. The plate No. XXIII. is of interest as showing a spurious form of perforation, and also the primary form of displacement of the fragments in stellate fractures. It was produced by a reversed ricochet, but undeformed, bullet, still seen in position in the skiagram; the bullet only possessed sufficient force to perforate the bone, and then appears to have turned on its transverse axis. The following plate, No. XXIV., is inserted to show the depth at which the bullet lay, and its distance from the surface of the tibia, which appears in the first plate to be nil. It is also of interest as showing the ease with which a false impression may be obtained from a single picture, as, beyond a spot of transparency, no obvious injury to the fibula, and certainly no displacement, is discernible. [Illustration: PLATE XXIV. Skiagram by H. CATLING. Engraved and Printed by Bale and Danielsson, Ltd. (41_a_) This skiagram is inserted to show the depth at which the bullet lay from the surface. It is also interesting to note the insignificance of the fracture of the fibula from this aspect. Without the second skiagram the injury might have passed for a simple perforation or a transverse fracture.] Fractures of the bones of the leg possessed an unenviable degree of importance. First, on account of the very severe injuries to the soft parts that often accompanied them, without an apparently correspondingly serious damage to the bone. Secondly, on account of the frequency with which the vessels were implicated in these injuries to the soft parts, either by the bullet or bone fragments. Beyond this, fracture of either articular end of the tibia was certainly more frequently followed by troublesome joint complications than occurred in the case of any other bone. In the matter of 'explosive' injuries, I think more were seen in the calf of the leg than in any other part of the body, and this often without solution of continuity of the bones, and sometimes without evidence even of contact of the bullet with either tibia or fibula. Some remarks on this subject have already been made in the chapter on wounds in general, and some sources of fallacy exposed. I believe that in practically all these so-called explosive injuries the wound was either caused by a ricochet, or a bullet which deformed with great ease on bony contact during its progress through the limb. A considerable number of the wounds which were referred by the men to the use of expanding bullets were probably the result of the use of Martini-Henry or large leaden sporting bullets, and evidence of this was often forthcoming on examination of the entry wounds. In other cases the irregularity of the opening plainly pointed to ricochet of a small bullet as the explanation of the character of the injury. The greater frequency of ricochet injuries in the leg and foot when the men were standing is readily understood. Concurrent injury to the vessels of the leg was common, but primary hæmorrhage, as was the case generally, usually ceased spontaneously. The importance of injury to the vessels was rather in view of secondary hæmorrhage, which occurred with some frequency, and I think more commonly from the anterior than the posterior tibial vessels, usually occurring at the end of a week or ten days, and naturally most frequently in cases which suppurated. _Prognosis and treatment in fractures of the leg._--In fractures of the leg, except those of extreme severity, almost any form of splint sufficed to maintain the bones in position, but for field purposes the Dutch cane splint (fig. 58, p. 222) was certainly very convenient. For later use in cases that needed frequent dressing, a wooden back splint, with a foot-piece, or, if obtainable, a Neville's splint with a suspension cradle, was the best. Where the wounds were small and frequent dressing was not required, nothing was so good as plaster of Paris, especially when transport was a necessity. [Illustration: FIG. 58.--Dutch Cane Field Emergency Splint for Leg] In cases with large wounds suppuration was very frequent, and in connection with this secondary hæmorrhage, or in the case of fractures near the articular ends, especially the upper, joint suppuration. The treatment of these cases varied: in many an amputation was the best or only treatment advisable; but I several times saw good results follow ligation of the anterior tibial artery for secondary hæmorrhage, even when suppuration existed, and occasional good results after incision and drainage of joints if the infection was not of the most acute form. Primary amputation was rarely needed for any case of injury from a bullet of small calibre, since it was only necessary either in the case of injury to both main arteries, and this was rare, or in cases of very extensive injury to the soft parts. I saw many of the latter make fair results when treated conservatively, even though the condition seemed almost hopeless at first sight. All the primary amputations that I saw were either for shell or large bullet injuries. A word may be inserted here as to the weight that ought to attach to nerve injuries in this relation. From the experience gained elsewhere it is clear that we should attach little importance to these unless the divided nerves are actually in sight, as far as deciding on amputation is concerned. On the other hand, there is little doubt that the presence of concurrent nerve injury, be it only concussion or contusion, exerts an important ulterior influence on the healing of the wound, whether the part be amputated or not. Amputation flaps in such cases possess a very considerably lowered degree of vitality. Secondary amputations were often needed for sepsis, and on the whole did very well; both for the same cause and for hæmorrhage intermediate amputations had occasionally to be performed; the results of these, as elsewhere, were bad. _Fractures of the tarsus._--Wounds of these short bones were as a rule of slight importance, given fairly direct impact on the part of the bullet. They then consisted of either simple perforations or surface grooving. A single bone might be implicated or several might be tunnelled; in the latter case the implication of the joints very considerably influenced the prognosis, since the addition of the joint injury caused much more prolonged weakening of the foot. Wounds of the foot were common from the fact that when the men lay out in the prone position, the foot was often the part least protected by the cover chosen, and particularly the heel. In these circumstances the os calcis was the bone most frequently implicated, and that by tracks taking an oblique course downwards from the leg to the sole. Again the foot was often struck by ricochet bullets, as a result of its position when the erect attitude was assumed. The latter fact was of much importance with regard to the nature of the injury sustained by the bones, as under these circumstances the mode of impact was irregular, and consequently comminution was often produced. The behaviour of the different bones of the tarsus varied somewhat. On the whole the prognosis in cases of injury to the os calcis was the best, since the injury was more often individual and did not implicate any joint, and also because of the comparatively regular architecture of the bone. In the smaller bones concurrent injury to a joint was more frequent. In the astragalus the central hard core extending upwards from the interosseous groove, as increasing resistance, I think accounted for the fact that comminution was more marked in this bone than in any other. The effect of wound of bones of the tarsus in producing a certain degree of laxity in the mediotarsal joint resulting in a slightly flexed position of the fore part of the foot and some projection of the head of the astragalus did not seem to me easy of explanation, but it occurred with some regularity. The injuries to the _metatarsus_ corresponded so nearly to those already spoken of in the case of the metacarpus that they need no further mention. They were less common, however, and I am under the impression that fragmentation of the bullet was not such a marked feature, probably on account of the lower degree of density of the bones, and their greater fixity of position. FOOTNOTES: [18] Col. W. F. Stevenson. _Loc. cit._ p. 69. CHAPTER VI INJURIES TO THE JOINTS Until recent times gunshot injuries of the joints formed a class entailing the gravest anxiety to the surgeon, both in regard to the selection of primary measures of treatment and in the conduct of the after progress of the cases. The external wounds were severe, comminution of the bones was great, and retention of the bullet within the articulation was not uncommon. Operative surgery therefore found a large field in the extraction of bullets, removal of bone fragments, excision of the joints, or even amputation of the limbs. The introduction of bullets of small calibre has robbed these injuries of much of the importance they possessed in earlier days and during the present campaign direct clean wounds of the joints were little more to be dreaded than uncomplicated wounds of the soft parts alone. No more striking evidence of the aseptic nature of the wounds, and the harmless character of the projectile as a possible infecting agent, than that offered by the general course of these injuries in this campaign, is to be found in the whole range of military surgery. The aseptic nature of the wounds, and the slight and localised character of the bone lesions, have in fact justified the opinion previously expressed by Von Coler, that these injuries in the future would be less feared than fractures of the diaphyses of the bones. Not less important than the localised character of the bone lesion itself is the fact that the accompanying wounds of the soft parts retain the small or type forms. Thus I occasionally observed more troublesome results from minor shell wounds in the neighbourhood of joints, but not implicating the synovial cavity, than in actual perforating injuries produced by bullets of small calibre. _Vibration synovitis._--Before proceeding to the consideration of wounds of the joints, a short account is necessary of a condition of some importance which is, I believe, more or less special to injuries from bullets of small calibre travelling at high rates of velocity. This condition, if not novel, at any rate excited little comment in the descriptions of the older forms of injury, although this may have depended on the more serious nature of the primary local lesions accompanying wounds from the larger bullets, among which it formed a comparatively unimportant element. The condition referred to was the occurrence of considerable synovial effusion into the joints of limbs in which the articulation itself was primarily untouched. These effusions sometimes occurred even when the soft parts alone were perforated, especially when the wounds were situated above or below the knee-joint. They were apparently the direct result of vibratory concussion of the entire limb dependent on the blow received from the bullet. The effusions were most strongly marked in cases of fractures of the diaphyses, although this was more noticeable in some situations than others. Thus with fractures of the shaft of the femur anywhere below the junction of the upper and middle thirds of the bone, and in some cases even higher, effusion into the knee-joint was very common, and sometimes extreme. On the other hand, similar effusions into the hip-joint were less marked, since I failed to determine their existence in the majority of cases. I am inclined to ascribe this to the different anatomical arrangement of the two joints, particularly to the fact that the head of the femur is included in a bony cup, into the hollow of which it is accurately fixed by the resilient cotyloid fibro-cartilage. The latter by its firm grasp of the head allows of little play in the joint; hence vibrations are conveyed directly to the acetabulum in continuous waves, and rocking of the articular surfaces is prevented. Beyond this no doubt the difficulty of detecting small effusions in this joint is an element which must be taken into consideration. I do not think that wrenches of the knee-joint in the act of falling can be suggested as an explanation of the frequency of effusions into that articulation, since the fractures of the femur were not always received while the erect position was maintained, and effusion was most marked when the diaphysis was the part affected, the latter point illustrating the greater resistance offered by compact bone. Again, when fracture had taken place, the solution of continuity rendered the directly injured point the most mobile, and tended to prevent lateral strain from falling on the joints. Effusion into the knee or ankle, or sometimes both joints, was common in fractures of the shaft of the tibia. In the articulations of the upper extremity the condition was also common, but somewhat less marked than in the lower limb. Effusions into the shoulder or elbow occurred. In the former these were less striking; again, perhaps, as a result of the difficulty of detecting small effusions in this situation. The elbow was to a certain extent protected by the possession of a degree of fixity somewhat resembling that already mentioned in the case of the hip-joint, although here depending on the conformation of the bones alone. I think this explained the absence of free effusion in many cases of fracture of the humeral shaft, but when the latter affected the lower third effusion into the elbow was usually abundant. The lighter weight and greater mobility of the upper extremity as a whole, as decreasing the resistance to the bullet, were also probably an element in the fact that these effusions were less severe than those in the joints of the lower limb. The nature of the effusions was apparently simple, since they were rapidly reabsorbed, and little thickening of the synovial membrane remained to suggest either a marked degree of inflammation, or the deposition of blood-clot on the inner aspect of the same. The only treatment indicated was a short period of rest, accompanied in the early stages by pressure and slight fixation, followed later by massage and movement if necessary. Before dismissing this subject, I should like to particularly emphasise the fact, that in the cases described there was no reason to suspect the extension of fissures from the point of fracture in the shafts into the articular ends of the bones. This was as far as possible excluded by clinical examination, and in the cases where wounds of the soft parts only were present, the rapid return of the patients to active duty, with absence of remaining joint trouble, negatived the possibility of such fractures. I only saw one case in which a longitudinal fracture actually extended for any considerable distance into a neighbouring joint. In this a comminuted fracture occurred just above the centre of the shaft of the humerus. At the time of examination and putting up of the fracture there was considerable swelling of the whole arm, and nothing special was noticed about the shoulder-joint. Three weeks later, however, when the fracture was consolidating, difficulty in abduction of the shoulder was noted, and the arm could not be placed closely in contact with the trunk. There was no evident displacement of the head of the humerus forwards. A skiagram, which I much regret I have not been able to insert, showed that a longitudinal fissure extended from the seat of fracture upwards in such a manner as to divide the upper fragment into two parts, of which the outer bore the greater tuberosity, the inner the articular surface of the head. The latter fragment had become somewhat displaced downwards, and had united in such a manner that the head rested on the lower part of the glenoid cavity. Abduction of the limb therefore brought the greater tuberosity into contact with the acromion process, and movement was checked. This case passed out of my observation shortly afterwards, and I have no knowledge of the final result as to movement. Fractures of the bony processes surrounding the elbow-joint, and of the malleoli of the tibia and fibula, were not infrequent, but offered no special features. One other form of injury indirectly affecting the joints is perhaps worthy of mention, but I observed it only once, and that in the case of the shoulder, the only joint where it is likely to be marked. I refer to the displacement of the head of the humerus by the force of gravity, when the circumflex nerve is injured. In the instance I refer to, a fracture of the surgical neck of the humerus was accompanied by complete motor paralysis of the deltoid and very rapid wasting of the muscle. Circumflex sensation was impaired, but not absent at the time the condition of the muscle was noted--a favourable prognostic sign of much importance. At the end of five weeks, when the fracture of the bone was consolidated, the head of the humerus had dropped vertically at least an inch, but could be replaced with ease. Shortly afterwards an improvement in the condition of the muscle commenced, and with this the head of the humerus was gradually raised. This patient later recovered his power in great part, but not completely. In a few cases bullets lodged in the neighbourhood of joints in such positions as to limit movement by mechanical impact with the bones. Thus I saw one case in which a bullet lay between the radius and ulna just below the lesser sigmoid cavity; in another the bullet lay in front of the ankle-joint, and limited the possibility of flexion; and in a case related to me by Mr. Bowlby, a bullet was removed by him from the wall of the acetabulum where it was tightly fixed in the substance of the bone. In two other cases I saw bullets lying deeply on the anterior surface of the hip capsule and so limiting flexion. In all such cases the indication for removal of the bullet was sufficiently strongly marked. WOUNDS OF THE JOINTS These may be divided into several classes, varying much in comparative severity, and in prognostic importance. 1. The comparatively rare instances in which a wound implicated a joint cavity, without accompanying lesion of any bone. 2. Perforating wounds in which the bullet was retained within the articular cavity. These were also rare. 3. Wounds of the joints accompanied by grooving of the articular extremities of the bones. 4. Complete perforating tracks through the articular ends of the bones, crossing the joint cavity in various directions. 5. Comminuted fractures of the terminal parts of the diaphyses extending into joints. Of these several classes, the first was of the least prognostic importance. In the absence of bone injury the wounds usually healed without any obvious ill effect beyond the transient effusion into the joints of a mixture of blood and synovial fluid. When suppuration of the wound in the soft parts occurred, however, the remarks made as to the injuries classed under the third heading also apply here in a lesser degree. With regard to the retention of the bullet, in the case of bullets of small calibre this was a distinctly rare occurrence. I never happened to see an instance of retention of either a Mauser or Lee-Metford bullet in an articulation. It is only possible with bullets practically spent, or travelling at a very low rate of velocity and making irregular impact. The influence of both volume and velocity of flight was well illustrated by my own small experience of retained bullets. In one case a Martini-Henry was found impacted between the femoral condyles, having slipped in beneath the margin of the patella. It caused a semiflexed position to be assumed by the joint, and was removed by Mr. Brown in No. 1 General Hospital at Wynberg. The second instance I saw in the Portland Hospital at Bloemfontein in a patient of Mr. Bowlby's. The bullet was a Guedes, a form which has been already described as possessing low velocity and deficient power of penetration; beyond this, in the particular instance irregular impact was evidenced by the presence of a large irregular contused wound of entry over the tuberosity of the tibia. The presence of the bullet in the knee-joint was later determined by the X-rays, and Mr. Bowlby removed it successfully. Seven months later the range of movement was nearly normal. I may add that I saw several instances of large leaden bullets lodging in the popliteal space, and a comparatively insignificant number of bullets of small calibre in the same situation. This was very striking, in view of the immense relative frequency of use of the latter forms. There is no doubt, moreover, that small bullets rarely lodge even in the neighbourhood of joints, unless at the distal end of a long track. To take the extreme example of large bullets, those employed as shrapnel, in comparison with the frequency with which wounds were produced by them, bullets lying at the bottom of short tracks in the neighbourhood of joints were not uncommon. Thus I saw one lying over the hip-joint, and another in close proximity to the shoulder capsule. Wounds of the third class, where the bones had been superficially grooved, were in some respects the most serious. This was especially so in the knee and ankle joints, and some cases will be quoted later under the heading of the special joints to illustrate this point. Danger only arose in the event of suppuration; and here the presence of the long oblique superficial track in a neighbourhood liable to comparatively free movement was the important element. Such tracks usually opened the synovial sac more extensively than direct perforating wounds, and if suppuration occurred in any portion of the track, the pus was very liable to be sucked into the joint on any free movement. The presence of fine splinters of the bone displaced in the production of the groove was also a special character of wounds of this class. Another point worthy of mention is that in these cases it was not always easy to be quite certain whether the joint cavity had been implicated or not, since cases often occurred in which, although the bones had been grooved, the joint cavity escaped. The indication, however, was to consider any wound in the immediate proximity of a joint as perforating until it was healed. This course was the more easy to take, since a large proportion of such wounds were accompanied by some degree of synovial effusion, even when the neighbouring joint had escaped puncture. Wounds of the fourth class, although the most highly characteristic of the form of accident, were in many instances the most favourable in regard to their course. The tracks might course directly across the joint in any direction, or they might course obliquely, traversing either one or both the component bones. In the latter case the exit might be in the diaphysis, and be accompanied by the separation of an exit fragment such as is illustrated in fig. 52, p. 169. The particularly favourable character of the direct transverse and antero-posterior wounds depended on the slight amount of splintering of the bones, the limited nature of the opening into the joint, and the shortness of the tracks in the soft parts, which ensured that, even if infection did occur, the resulting pus was near the surface, and generally spread in that direction and escaped. Wounds of the fifth class were the most dangerous, but the danger was entirely a secondary one, dependent on the occurrence of infection. These injuries were liable to be accompanied by the presence of extensive irregular wounds of the soft parts, in which suppuration was frequent, and the suppuration of the joint frequently meant subsequent amputation, if not a worse result. _Course and symptoms of wounds of the joints._--The immediate result of any perforation of a joint was the development of intra-articular effusion. This consisted of synovial fluid admixed with a varying proportion of blood. The degree of synovitis was apt to vary with the amount of force expended in the production of the injury; for this reason both high velocity and irregular impact were of importance in this relation. The constant feature, however, depended on the effusion of blood; this was not rapid, or, as a rule, very abundant, but tended to increase during the first twenty-four hours. It resulted in a swelling of the joint, which possessed some peculiar features. At first elastic and resilient, it slowly decreased in volume with the assumption of a soft doughy character on palpation. In the case of the knee, where readily palpated, it very much resembled a tubercular synovial membrane, except for its extreme regularity of surface; still more closely the condition noted in a hæmophilic knee of some duration. Absorption took place with some rapidity, and except for slight thickening, the joints might appear almost normal, in a period of from two to four weeks. With the development of the effusion there was local rise in temperature of the surface, and in a considerable number of the cases a general rise of temperature. This latter was sometimes very marked, as in the case of all the other traumatic blood effusions, but not quite so regular in occurrence. It was important, as I have seen it give rise to the suspicion of suppuration, when tapping resulted in nothing more than the evacuation of turbid synovia mixed with blood. Pain was rarely a prominent symptom in consequence of the generally moderate degree of distension. As a rule, these injuries were characterised by the small tendency to the development of adhesions; but this in great part depended on the care expended on their treatment. If kept too long quiet, either from necessity when the effusion was followed by much thickening, or when the external wound was large and so situated as to be harmfully influenced by movement, or in the ordinary course of treatment, troublesome stiffness, even amounting to firm anchylosis, sometimes followed. I saw several such cases, some of the most confirmed being wounds of the knee-joint complicated by injury to the popliteal vessels or nerves. The latter complication I saw altogether six times, but only once with a thoroughly bad knee, and in this case the injury had affected both the vessels and the internal popliteal nerve. The joint in that case was straightened out by continuous extension by Major Lougheed, when it came under his charge some six weeks after the primary injury, but I hear has again relapsed, and the popliteal paralysis is not much improved. The small tendency to formation of adhesions in uncomplicated cases probably depended on the coagulation of a layer of blood over the whole internal lining of the joint. This kept the synovial surfaces apart at the lines of reflection of the membrane, and, given sufficiently active treatment, mobility was restored before any firm union could take place. The primary escape of synovial fluid was rarely observed, as the wounds of the soft parts were too small and valvular to permit of it. Synovia in some abundance, mixed with pus, sometimes escaped in considerable quantity when infection had opened up the tracks. Primary suppuration in any joint as a result of small and direct wounds was very rare. I observed it only on one occasion. On the other hand, a considerable number of cases in which secondary suppuration occurred came under my notice. In some of these the suppuration was secondary to comminuted fractures of the shaft of the tibia, in which the articular extremity was implicated. These offered no special peculiarity. In others infection of the joint was secondary to infection and suppuration in the deep part of long oblique wound tracks, and these were of sufficient interest to warrant the insertion of two illustrative cases. (43) In a man wounded at Paardeberg the bullet entered the leg to the inner side of the crest of the tibia, about 3 inches below the tubercle; thence it coursed upwards to emerge about 2 inches above the cleft of the knee-joint on the outer side. Regulation dressings were applied, and a week later the man arrived at the Base, with little apparent mischief in the knee-joint. He was placed in bed and warned against movement; on the second day, however, he got up and walked to the latrine. When bending his knee to sit down he was seized with agonising pain in the joint, and had to call out for help; he was then carried back to bed in a more or less collapsed condition. The knee commenced to swell; there was rise of temperature and great pain, together with extreme restlessness. I was asked to see him two days later, and after a consultation, Major Burton, R.A.M.C., freely incised the knee-joint bi-laterally. One opening was closed, the second plugged for drainage, as there was a large quantity of pus. No improvement followed, and a week later Major Burton amputated through the thigh. An attack of secondary hæmorrhage a few days later, combined with the degree of septic infection, ended the man's life. On examination of the joint, a groove forming three-fourths of a tunnel was found in the external tuberosity of the tibia, leading into the knee-joint beneath the external semilunar cartilage. The bullet had then passed upwards over the outer border of the cartilage, bruised the margin of the external condyle of the femur in such a manner as to depress the outer compact layer, and finally escaped from the joint near the upper reflection of the synovial membrane. The synovial membrane was granular in appearance and reddened, but there was no suppuration outside the confines of the joint, except in a cavity corresponding to 2 inches of the track before it actually perforated the tibia. A localised abscess had evidently formed here and been diffused into the joint by the movement of flexion already described. (44) A man wounded during General Hamilton's advance on Heilbron was struck on the outer aspect of the heel. An oval opening of some size led down to a track in the os calcis; the bullet was retained. The foot was dressed, and put up later in a plaster-of-Paris splint. On the tenth day the splint was removed to see to the wound, which looked satisfactory and was re-dressed. A few hours later the man was seized with very severe pain in the ankle, and a day later I was asked to see him by Mr. Alexander. The man was anæsthetised, and I examined the wound with care, and also removed the retained bullet from the inner margin of the leg. The bullet was reversed, having no doubt suffered ricochet, hence the large aperture of entry, but it was in no way deformed. I could not certainly determine the presence of any fluid in the ankle-joint, and as the pain was apparently localised to the distribution of the musculo-cutaneous nerve, I decided not to freely open the joint. In this, however, I erred, and two days later, after consultation, the joint was freely incised by Mr. Alexander. It was then found that the bullet in its passage had just touched the posterior aspect of the tibia and wounded the ankle-joint. A localised collection of pus which had formed in the deep part of the wound had been diffused into the joint by the movements made when the splint was removed, in a similar manner to that described in the last case. This joint also did badly, and an amputation of the leg had to be performed by Mr. Alexander to save the man's life. These two cases are particularly instructive as showing, first, how quietly a small amount of deep suppuration may sometimes take place; and, secondly, the importance of keeping the joints quiet on a splint when there is any reason to suspect their implication by wounds of this character. _The general treatment_ of the wounded joints was simple. The old difficulties of deciding on partial as against full excision, or amputation, were never met with by us. We had merely to do our first dressings with care, fix the joint for a short period, and be careful to commence passive movement as soon as the wounds were properly healed, to obtain in the great majority of cases perfect results. Careful light massage, if available, was used to promote absorption of blood. If suppuration occurred, the choice between incision and amputation had to be considered. In the early stages this choice depended entirely on the nature of the injury to the bones. If this were slight, incision was the best plan to adopt. I saw several cases so treated which did well, although convalescence was often prolonged, and only a small amount of movement was regained. Amputation was sometimes indicated in cases of severe bone-splintering, when the shafts were implicated, but was as a rule only performed after an ineffectual trial to cut short general infection of the septicæmic type by incision. I have dwelt at such length on the subject of suppuration on account of its importance, but I should add that, on the whole, suppuration of the joints was uncommon, except in the case of injuries far exceeding the average in primary severity. _Special joints._--Such deviations from the general type of injury as above described depended entirely on peculiarities of anatomical arrangement, and peculiarities in the situation of the joint clefts in the different parts of the body. A few words as to these are perhaps necessary. _Shoulder-joint._--Wounds of this articulation were by no means common. This depended, I think, on two points in the architecture of the joint: first, a bullet to enter the front of the cavity and traverse the joint needed to come with great exactitude from the immediate front; secondly, wounds received from a purely lateral direction calculated to pierce the head of the humerus and the glenoid cavity were naturally of very rare occurrence. Wounds of the prominent tip of the shoulder received while the men were in the prone position were not uncommon, but it was remarkable how rarely the shoulder-joint was implicated in these. The question of the narrow nature of the cleft exposed also comes up in this position. As far as my experience went, injuries to the lower portion of the capsule accompanying wounds of the axilla were those most often met with. The ease and neatness with which pure perforations of the head of the humerus can be produced was also an important element in the frequent escape of this joint. No case of fracture of the glenoid cavity happened to come under my notice. I saw few instances in which the joint needed incision, and cannot recall or find in my notes any case in which serious trouble arose. _Elbow-joint._--Injuries to this joint came second in frequency in my experience to those of the knee. They were, in fact, comparatively common, especially in conjunction with fractures of the various bony prominences surrounding the articulation. Fractures of the lower end of the humerus were of worse prognostic significance than those of the ulna, on account of the greater tendency to splintering of the bone. I saw several cases of pure perforation of the olecranon without any signs of implication of the elbow-joint. In a case which has been utilised for the illustration of some of the types of aperture (fig. 20, p. 59), at the end of a week there was no sign of any joint lesion, although the bullet had obviously perforated the articulation. Several cases of suppuration which came under my notice did well. I saw one of them a few days ago, six months after the injury, with perfect movement. In another of which I took notes, the bullet entered over the outer aspect of the head of the radius, to emerge just above the internal condyle anteriorly. A considerable amount of comminution of the olecranon resulted, and when the man came into hospital some ten days later the joint was suppurating. The joint was opened up from behind, and some fragments of bone removed by Mr. Hanwell. On the 26th day this joint was doing well, and considerable flexion and extension were possible without pain. There was a somewhat abundant discharge of bloody synovia during the first few days after the operation. [Illustration: FIG. 59.--Illustrates the very neat and limited injury to the Phalanges over the dorsal aspect of the first inter-phalangeal joint of the Middle Finger, accompanying a gutter wound received by the patient while holding a rifle.] I never saw any troublesome results from perforations of the _carpus_. The joints of the _fingers_ also offered little special interest, except in so far as they afforded astonishing examples of the extreme neatness of the injuries which a small-calibre bullet can produce. Fig. 59 is a good example of such an injury. _Hip-joint._--I can only repeat with regard to this joint what I have already said as to the injuries to the head of the femur. I had practically no experience of small-calibre bullet injuries to the femoral constituent, and beyond the single case of injury to the acetabular margin mentioned on p. 193 I saw no obvious wounds of the joint at all. _The knee_, as usual, proved itself _par excellence_ the joint most commonly injured, no doubt as a result of its size, the extent of its capsule anteriorly, and its exposed position. In spite, however, of the frequency with which it suffered injury, and the opportunities it afforded for observation of the progress of the effusions towards absorption, the injuries to the joint gave less anxiety and attained a more favourable prognostic character than is the case in civil practice. This depended on the very favourable course observed in the frequent pure perforations following a direct line. These occurred in every direction, the accompanying hæmarthrosis usually disappearing completely in an average period of little over a month. The extremes can be fairly placed at a fortnight and six weeks. Limitation of movement was slight or non-existent in many cases; in others it was of a very moderate character, and I only remember to have seen one case in which a really serious anchylosis developed. In this the man was struck from a distance of 300 yards, and a considerable amount of bone dust from the femur was found in the lips of the exit aperture. The wounds healed _per primam_, but when I saw the man two months later anchylosis in the straight position was apparently complete. The comparatively frequent association of popliteal aneurisms with wounds of the knee-joint has already been spoken of in relation to anchylosis. Wounds of the popliteal space from larger bullets sometimes caused more troublesome after-stiffness than wounds of the articulation itself. Again I remember a small pom-pom wound at the inner margin of the ligamentum patellæ without obvious wound of the joint, which was accompanied by synovitis from contusion, and was followed by very considerable limitation of movement. This had only been partially improved when the patient returned home, in spite of prolonged massage and passive movement. The general remarks on the joints cover all that need be said as to suppuration of the knee-joint. _The ankle-joint_ maintained the undesirable character which it has always held as a subject for gunshot injuries. This is entirely a question of sepsis, and in great measure depends on the fact that the foot, as enclosed in a boot, is invested with skin particularly difficult to thoroughly cleanse; while the socks are an additional source of infection to the wounds before the patients come under proper treatment. Of seven cases of suppurating ankle-joint, of which I have notes, only two retained the foot, and one of these after a very dangerous illness. This case was one of special interest as exemplifying the results dependent on variations in velocity on the part of the bullet. The patient was struck at a distance of twenty yards. The bullet entered the front of the right ankle-joint and emerged through the internal malleolus, just behind its centre, causing no comminution of the latter. It then entered the left foot by a type wound one inch behind and below the tip of the internal malleolus, traversed and comminuted the astragalus, and emerged one inch below the tip of the external malleolus. The first joint healed _per primam_. The second produced by the bullet when passing at a lower rate of velocity was accompanied by considerable comminution of the bone. It suppurated, and gave rise to great anxiety both for the fate of the foot and the life of the patient. It is probable that the more abundant hæmorrhage which took place from the second wound was in part responsible for the occurrence of infection. The second of the two cases is of some interest in relation to the doctrine of chances as to the position in which a wound may be received. The man was wounded in one of the earlier engagements, a bullet passing transversely through his leg immediately behind the bones and about half an inch above the level of the ankle-joint. He recovered, and rejoined his regiment, only to receive at Paardeberg a second wound, about an inch lower, which traversed the ankle-joint. On his return to Wynberg he happened to be sent to the same pavilion, and occupied the same bed he had left on returning to the front. The subject of the result of wounds of the joints of the _foot_ has received sufficient consideration under the heading of wounds of the tarsus. The repetition of the fact that, among the whole series of cases on which this chapter is founded, not a single instance of primary or secondary excision of a joint, either partial or complete, is recorded, forms an apt conclusion to my remarks on this subject. CHAPTER VII INJURIES TO THE HEAD AND NECK Injuries to the head formed one of the most fruitful sources of death, both upon the battlefield and in the Field hospitals. It has been suggested that the mere fact of wounds of the head being readily visible ensured all such being at once distinguished and correctly reported, while wounds hidden by the clothing often escaped detection. When the external insignificance of many of the fatal wounds of the trunk is taken into consideration this is possible; but, on the other hand, it must be borne in mind that the head is in any attitude the most advanced, and often the most exposed, part of the body, and even when the soldier had taken 'cover,' it was frequently raised for purposes of observation. For the latter reasons I believe injury to the head fully deserved the comparative importance as a fatal accident with which it was credited. A number of somewhat sensational immediate recoveries from serious wounds of the head have been placed upon record. Observation, however, shows that these, with but few exceptions, belonged either to certain groups of cases the relatively favourable prognosis in which is familiar to us in civil practice, or that the wounds were received from a very long range of fire, and hence the injuries were strictly localised in character. ANATOMICAL LESIONS _Wounds of the scalp._--Nothing very special is to be recorded with regard to these; they either formed the terminals of perforating wounds, or were the result of superficial glancing shots. The glancing wounds were of the nature of furrows, varying in depth from mere grazes to wounds laying bare the bone. Their peculiarity was centred in the fact that a definite loss of substance accompanied them, the skin being actually carried away by the bullet; hence gaping was the rule. Every gradation in depth was met with, but the only situations in which wounds of considerable length could occur were the frontal region in tranverse shots, or, when the bullet passed sagitally, the sides of the head, or the flat area of the vertex. The danger of overlooking injuries to the bone was of special importance in the short subcutaneous tracks occasionally met with at the points at which the surface of the skull makes sharp bends. In all such wounds it was a safe rule to assume a fracture of the skull until this was excluded by direct examination. In some of the gutter wounds and subcutaneous tracks crossing the forehead and sides of the head, signs of intracranial disturbance were occasionally observed in the absence of external fracture, such as transient muscular weakness, unsteadiness in movements, giddiness, diplopia, or loss of memory and intellectual clearness. In connection with such symptoms the classical injury of splintering of the internal table of the skull, the external remaining intact, had to be borne in mind, but I observed no proven instance of this accident. I am of opinion, moreover, that its occurrence with small bullets travelling at a high degree of velocity must be very rare, since little deflection is probable unless the contact has been sufficiently decided to fracture the external table; while in the cases of spent bullets the injury is unlikely, as requiring a considerable degree of force. _Injuries to the cranial bones, without evidence of gross lesion to the brain._--It may be premised that these were of the rarest occurrence, and they may be most readily described by shortly recounting the conditions observed in a few cases I noted at the time. The injuries resulted from blows with spent bullets, from bullets barely striking the skull directly, or those striking over the region of the frontal sinuses. Wounds of the mastoid process will not be considered in this connection as being of a special nature (see p. 299). I saw only one case of escape of the internal, with depressed fracture of the external, table of the skull. (45) In marching on Heilbron a man in the advance guard was struck by a bullet at right angles just within the margin of the hairy scalp. The regiment was at the time to all intents and purposes outside the range of rifle fire, and the patient was the only individual struck among its number. When brought into the Highland Brigade Field Hospital, a single typical entry wound was discovered; examination with the probe gave evidence of a slight depression in the external table of the frontal bone just above the temporal ridge. Although no perforation was detectible by the probe, and this was positively excluded on the raising of a flap (Major Murray, R.A.M.C.), it was considered advisable to remove a 1/4-inch trephine crown, the pin of the instrument being applied to the margin of the depression. No depression or splintering of the internal table was discovered, nor any injury to the dura, nor blood upon the surface of that membrane. The man made an uninterrupted recovery. (46) A case of frontal injury was shown to me at Wynberg, in which a distinct furrow could be traced across the upper part of the frontal sinuses. There had been no symptoms beyond temporary diplopia, and the wound was healed; no surgical interference had been deemed necessary. (47) In a man wounded at Poplar Grove, a single typical wound of entry was found 3/4 of an inch above the right eyebrow and the same distance from the median line. No primary symptoms were observed, but on the evening of the second day the temperature rose above 100° F., and the man seemed somewhat heavy and dull. The patient was examined by Major Fiaschi and Mr. Watson Cheyne, and it was decided to explore the wound. Mr. Cheyne removed fragments both of external and internal tables, one of the latter having made a punctiform opening, not admitting the finest probe, in the dura-mater. The bullet was traced into the nasal fossæ, where it was subsequently localised with the aid of the Roentgen rays when the patient came under my observation at Wynberg some days later (fig. 60). _Gunshot fracture of the skull with concurrent brain injury._--This was the commonest form of head injury, and possessed two main peculiarities; firstly, the large amount of brain destruction compared with the extent of the bone lesion; secondly, the fact that any region of the skull was equally open to damage. In consequence of the second peculiarity, the position and direction of secondary fissures are not so dependent on anatomical structure as in the corresponding injuries of civil practice. Thus, fractures of the base, for instance, were less constant in their course and position. The cases as a whole are best divided into four classes. [Illustration: FIG. 60.--Mauser Bullet in Nasal Fossa. (Skiagram by H. Catling.) Case No. 47] 1. Extensive sagittal tracks passing _deeply_ through the brain, and vertical wounds passing from base to vertex or _vice versa_, in the posterior two thirds of the skull. These will be referred to as general injuries. 2. Vertical or coronal wounds in the frontal region. 3. Glancing or obliquely perforating wounds of varying depth in any part of the head. 4. Fractures of the base. Of these classes the first was nearly uniformly fatal; the second relatively favourable, and with low degrees of velocity often accompanied by surprisingly slight immediate effects; while the third had perhaps the best prognosis of all, but this varied as to the defects that might be left, and with the region of the head affected. 1. _General injuries._--Fractures of this class may be treated of almost apart. For their production the retention of a considerable degree of velocity on the part of the bullet was always necessary, and the results were consequently both extensive and severe. The aperture of entry was comparatively small, since to take so direct and lengthy a course through the skull the impact of the bullet needed to be at nearly an exact right angle to the surface of the bone. Any disposition to assume the oval form, therefore, depended mainly upon the degree of slope of the actual area of the skull implicated. In size the aperture of entry did not greatly exceed the calibre of the bullet; in outline it was seldom exactly circular, but rather roughly four-sided, with rounded angles, slightly oval, or pear-shaped. The margin of the opening consisted of outer table alone, the inner being always considerably comminuted. Fragments of the latter, together with the majority of those corresponding to the loss of substance of the outer table, were driven through the dura mater and embedded in the brain. These bony fragments were more or less widely distributed over an area of a square inch or more, and not confined to a narrow track. [Illustration: FIG. 61.--Diagram of Aperture of Entry in Occipital Bone, showing radiating fissures exact length. The exit in the frontal region was of typical explosive character. Range '100 yards'.] The amount of fissuring at the aperture of entry was often not so extensive as I had been led to expect. Fig. 61 is a diagram illustrating a fairly typical instance; in some cases no fissuring existed. As a rule the nearer to the base, the greater was the amount of fissuring observed. The fissures were sometimes very extensive in this position, probably as a result of the lesser degree of elasticity in this region of the skull. Again, when the aperture of entry was near the parts of the vertex where sudden bends take place, considerable fissuring of the same nature as that seen in the superficial tracks (fig. 68) was produced in the flat portion of the skull above the point of entrance. Radial fissuring around the aperture of entry in the skull scarcely corresponds in degree with that seen when the shafts of the long bones are struck, and is far less marked and regular than when one of these small bullets strikes a thick sheet of glass set in a frame. I saw several apertures in the thick glass of the windows of the waterworks building at Bloemfontein produced by Mauser bullets. They differed little from the opening seen in an ordinary plate-glass window resulting from a blow from a stone, except perhaps in the regularity and multiplicity of the radial fissures. As in the skull, the opening was a little larger than the calibre of the bullet, and the loss of substance on the inner aspect considerably exceeded that on the outer. The degree of fissuring is probably affected by the resistance offered by the particular skull, or the special region struck, but as a rule the elasticity and capacity for alteration in shape possessed by the bony capsule, is opposed to the production of the extreme radial starring observed in the long bones or a fixed sheet of glass. Corroborative evidence of the influence of elasticity in the prevention of starring is seen in the limited nature of the comminution of the ribs in cases of perforating wounds of the thorax. In the most severe cases we can only speak of the 'aperture' of exit in a limited sense in so far as the opening in the scalp is concerned; this was often comparatively small, not exceeding 3/4 of an inch in diameter. Beneath this limited opening in the soft parts, the bone of the skull was smashed in a most extensive manner. The portion exactly corresponding to the point of exit of the bullet was carried altogether away, but around this point a number of large irregularly shaped fragments of bone, from 3/4 to 1 inch in diameter, were found loose, and often so displaced as to expose a considerable area of the dura-mater. Beyond the area of these loose fragments, fissures extended into the base and vertex, in the latter case often being limited in their extent by the nearest suture. Over extensive fractures of this nature general oedema and infiltration of the scalp, due to extravasation of blood, were present. When the exit was situated in the frontal region ecchymosis often extended to the eyelids and down the face, while in the occipital region similar ecchymosis was often seen at the back of the neck. The opening in the dura mater at the aperture of entry was either slitlike, or more often irregular from laceration by the fragments of bone driven in by the bullet. At the point of exit a similar limited opening corresponded with the spot at which the bullet had passed, while separate rents of larger size were often seen at some little distance. The latter were the result of laceration of the outer surface of the membrane by the margins of the large loose fragments of bone above described. Injury to the brain more than corresponded in extent to the fractures of the bone. Pulping of its tissue existed over a wide area both at the points of entrance and of exit. In the former position the amount of damage was the less, the gross changes roughly corresponding with the tissue directly implicated by the bullet itself, and the fragments of bone carried forward by it. The degree of splintering of the skull therefore in great part determined the severity of the lesion. At the exit aperture much more widespread destruction existed, while masses of brain tissue, small shreds of the membranes, fragments of bone, and _débris_ from the scalp were found occasionally bound together by coagulated blood and protruding from an exit opening of some size. The largest masses of such _débris_ were most often seen in instances in which the bullet had entered by the base to escape at the vertex of the skull. The brain in the line of injury suffered comparatively slightly, but small parenchymatous hæmorrhages into its tissue indicated in lesser degree the same type of injury undergone by the mass of brain pulp and small blood-clots found at the external limits of the wound. Beyond this extensive hæmorrhages at the base of the skull were common. With regard to the extensive character of the brain destruction in the region of the aperture of exit, it must be borne in mind that this lesion corresponds in position with one which would exist even if the injury were of a non-penetrating degree. A large proportion of the contusion and destruction is therefore explained by violent impact of the projected brain with the skull prior to the passage of the bullet, and not to the direct action of the bullet on the tissues. These cases of 'general injury' afford a marked example of the lesions to which the term 'explosive' has been applied, and as such have an important bearing on the theories held as to the mode of production of explosive effect. The increased area of tissue damage at the aperture of exit favours the theory of direct transmission of a part of the force with which the bullet is endowed, to the molecules of tissue bounding the track made by the projectile. Thus the area of destruction corresponds with the cone-like figure which one would expect to be built up by the vibrations spreading from the primary point of impact. The exit region of the skull is subjected not alone to the force of the travelling bullet, but also to that exerted over a much wider area by the tissue to which secondary vibrations have been communicated. The brain itself is, in fact, dashed with such violence against the bone as to cause a great part of the injury. No doubt the brain in its reaction to the bullet forms as near an approach to a fluid as any solid tissue in the human body, and experimental observation has shown how greatly its presence or absence in the skull affects the degree of comminution on the exit side; hence the fondness for the so-called hydraulic theory that has been always exhibited in the case of these injuries. The localisation of the injury in its highest degree to the neighbourhood of the exit aperture, however, shows that in any case the main wave takes a definite direction in a course corresponding to that of the bullet. The real importance of the presence of the brain within the skull in increasing the amount of damage at the exit end of the track, is as a medium for the ready transmission of forcible vibrations. That the latter are to some extent conveyed as by a fluid is evidenced by the occasional presence of brain matter and fragments of bone in the aperture of entry, which suggests recoil or splash such as would be expected from a fluid wave. Experience of the character of the lesions observed after severe concussion by the ordinarily somewhat coarser forms of violence common to civil life, fully explains the severity of the damage to the brain tissue met with in injuries due to bullets of small calibre. Viewing the elaborate arrangements which exist for the preservation of the central nervous system from the moderate vibration incidental to ordinary existence, it is easy to appreciate the harmfulness of such exquisite vibratory force as that transmitted by a bullet of small calibre travelling at a high rate of velocity. _Effect of ricochet in the production of severe forms of injury._--In connection with the lesions above described mention must be made of cases in which the aperture of entry reaches a large size, or a portion of the skull is actually blown away. Examples of the former class were not uncommon; I will briefly relate one. (48) A Highlander while lying in the prone position at Rooipoort, was struck by a bullet probably at a distance of about 1,000 yards. A large entry wound in the scalp was produced, while the defect in the skull was coarsely comminuted and was capable of admitting three fingers into a mass of pulped brain. Both brain matter and fragments of bone were found in the external wound, which was situated just anterior to the right parietal eminence. The bullet passed onwards through the base of the skull, crossing the external auditory meatus, fracturing the zygoma and probably the condyle of the mandible, and eventually lodged beneath the masseter muscle. Blood and brain matter escaped from the external auditory meatus. The patient was brought off the field in a semi-conscious condition, the pupils moderately contracted but equal, the pulse 66, very small and irregular in beat, the respiration quiet and easy, and with paralysis of the left side of the body. The fæces had been passed involuntarily. The wound was cleansed and bone fragments removed. The patient had to travel in a wagon for the next three days until the column halted. The progress of the case was unsatisfactory, as the wound became infected, and the man eventually died on the 14th day of general septicæmia, but with little evidence of local extension of septic inflammation. In this instance the head was no doubt struck by a bullet which had previously made ricochet contact with the ground. I saw several such cases. Closely connected with such injuries are those in which large portions of the skull and scalp were actually blown away. I never witnessed one of these myself, but I recall two instances described to me by officers who lay near the wounded men on the field. In one the frontal region was carried away so extensively that, to repeat the familiar description given by the officer, 'he could see down into the man's stomach through his head.' In a second case the greater part of the occipital region was blown away in a similar manner, and this was of especial interest as the wounded man was seen to sit up on the buttocks and turn rapidly round three or four times before falling apparently dead. The observation offers interesting evidence of the result of an extensive gross lesion of the cerebellum. In the absence of exact information, it may well be that such injuries as the two latter were produced by some special form of bullet, but as both were produced while the patients were lying on the ground, and therefore especially liable to blows from ricochet bullets, I am inclined to attribute both to this cause. In considering injuries of the above nature, one cannot help speculating on the possible influence of a head-over-heels ricochet turn on the part of the bullet while traversing the long sagittal axis of the skull. It is not uncommon for apical target ricochets to present evidence of damage to the apex and base of the mantle alone. This must depend on a rapid turn on impact, which might well be imitated in the case of the skull, and would then go far to explain the production of some of the most severe forms of explosive exit wounds met with. See cases 48, 54, 68. Short of ricochet, the influence of simple wobbling must also be considered in shots from a long range. The entry wound may be large as a result of this condition, but as the velocity possessed by the bullet is low, the injuries would probably not be of a very severe nature. In connection with the subject of wobbling, reference should be made to the form suggested by Nimier and Laval, in which the wobble, as the result of resistance to the apex of the revolving bullet, assumes the form of movement seen when the spin of a top is failing. This would explain a peculiarity in some wounds of entry over the skull first pointed out to me by Mr. J. J. Day. When such wounds were explored, as well as the presence of brain in the entry aperture, a number of fragments of the external table of the skull were found everted and fixed in the tissues of the scalp. As already suggested, this may be mere evidence of splash, but it may be equally well explained by a process of wobble around the axis of revolution of the bullet. This might, no doubt, also be invoked to explain the displacement of some of the fragments in fractures of the long bones, where considerable resistance to the passage of the bullet is offered. II. _Vertical or coronal wounds in the frontal region._--These injuries were common, and offered some of the most interesting illustrations of the variations in symptoms and effects following apparently exactly identical lesions, judging from the condition of the external soft parts alone; since the latter sometimes gave little indication of the force (dependent on the rate of velocity) which had been applied. With the lower degrees of velocity simple punctured fractures of the skull resulted, without extensive lesion of the frontal lobes as evidenced by immediate symptoms. The nature of the fractures differed in no way from the punctured fractures we are familiar with in civil practice. The openings of entry in the bone were irregularly rounded, corresponding in size to the particular calibre of the bullet concerned. The margin consisted of outer table alone, while the inner table was either considerably comminuted, or a large piece was depressed, wounding the dura-mater and projecting into the brain substance (see fig. 63). The aperture of exit presented exactly the opposite characters, the splintering comminution or separation of a large fragment affecting the outer table, while the inner presented a simple perforation. The latter condition is represented in figs. 71 and 72, and I will here give short notes of four illustrative cases, as being the shortest and most satisfactory method of conveying a correct idea of the nature of such injuries. [Illustration: FIG. 62--Aperture of Entry in Frontal Bone. Case No. 50. 1/2] (49) _Vertical perforation of frontal bone._--Wounded at Belmont, while in the prone position. Aperture of _entry_ (Mauser), at the anterior margin of the hairy scalp on the left side; course, through the anterior part of the left frontal lobe, roof of the left orbit, cutting the optic nerve and injuring the back of the eyeball, floor of the orbit, the antrum, the hard palate, and tongue. _Exit_, in mid line of the submaxillary region. No cerebral symptoms were noted, and on the fifth day the man was sent to the Base hospital without operation; the pulse was then 70 and the temperature normal. The movements of the eyeball were perfect, but blindness was absolute. At the Base hospital the eye suppurated and was removed. The patient was then sent home apparently well. He has since been discharged from the service, and is now employed as a painter in Portsmouth Dockyard. (50) _Vertical perforation of frontal bone._--Wounded at Paardeberg while in the prone position. Range, 600-700 yards. Aperture of _entry_ (Mauser), at the fore margin of the hairy scalp above the centre of the right eyebrow; course, through the anterior third of the right frontal lobe, roof of orbit, front of eyeball, margin of floor of orbit making a distinct palpable notch, and cheek; _exit_ through the red margin of the upper lip, 1/2 an inch from the right angle of mouth. The bullet slightly grooved the lower lip. The patient rose almost immediately after being struck, and walked about a mile, although feeling dizzy and tired. The wounds, which both bled considerably, were then dressed. After three days' stay in a Field hospital, the patient was sent in a bullock wagon three days and nights' journey to Modder River and thence to the Base. There was anæsthesia over the area supplied by the outer branch of the supra-orbital nerve, extending from the supra-orbital notch backwards into the parietal region, but none over the area supplied by the second division of the fifth nerve. On the tenth day there were no signs of cerebral disturbance except a pulse of 48. The eyeball was suppurating, and the temperature rose to 99° at night. The lids were still swollen and closed. A few days later the eyeball was removed and at the same time a flap was raised and the fracture explored (Major Burton, R.A.M.C.). An opening somewhat angular, 1/3 of an inch in diameter, was found with a thin margin in the outer table of the skull (fig. 62); when this was enlarged with a Hoffman's forceps, an opening in the dura was discovered, and cerebro-spinal fluid escaped. A piece of the inner table of the skull (fig. 63), 3/4 by 1/3 an inch in size, was discovered projecting downwards vertically into the brain. This latter was removed and the wound closed. Healing by primary union followed, and no further symptoms were observed. [Illustration: FIG. 63.--Fragment of Inner Table depending vertically from lower margin of puncture shown in fig. 62. The centre was perforated. Exact size] (51) _Transverse frontal wound._--Wounded at Paardeberg. The man was sitting down at the time he was struck, in the belief that he was out of the range of fire. The _entry_ and _exit_ wounds were almost symmetrical, placed on the two sides of the forehead at the margin of the hairy scalp, 2-1/4 inches above the level of the external angular processes of the frontal bone. The patient lost consciousness for about half an hour, then rose and walked half a mile to the Field hospital. The wounds were dressed, and after a stay of three days in hospital, the man was sent the three days' journey to Modder River; during the journey he got in and out of the wagon when he wished. After two days' stay at Modder, a journey was again made by rail to De Aar (122-1/2 miles). The wounds were healed. The man stayed at De Aar nearly a month, and then, rejoining his regiment, made a two days' march of some 22 miles on hot days. He had to fall out twice on the way by reason of headache, feeling dizzy, and 'things looking black.' He did not own to any loss of memory or intellectual trouble, but was invalided to England. This patient returned to South Africa later, and is now on active service. (52) _Transverse frontal wound._--Within a few days an almost identical symmetrical wound in the frontal region occurred in the same district, from a near range. The patient became immediately unconscious, and remained so until his death some four days later, his symptoms being in no way alleviated by operation and the removal of a quantity of bone fragments and cerebral _débris_. At the _post-mortem_ examination, extensive destruction of both hemispheres of the brain was revealed, and large fissures extended into the base of the skull. III. _Glancing or oblique perforating wounds of varying depth in any portion of the cranium._--These injuries were the most common, the most highly characteristic of small-calibre bullet wounds, the most interesting from the point of view of diagnosis, prognosis, and treatment, and beyond this they formed the variety most unlike any that we meet with in civil practice. They were met with in every region of the cranium, and in every degree of depth and severity. The lesser are best designated as gutter fractures, the deeper are perforating and gradually approximate themselves to the type of injury described as class 1. When the bullet struck a prominent or angular spot on the skull a considerable oval-shaped fragment was occasionally carried away, leaving an exposed surface of the diploë (case 60, p. 274). Under these circumstances the apparent lesion on raising a flap was slight, but exploration often showed extensive intra-cranial mischief. Thus in the case referred to both dura and brain were wounded, and continuing hæmorrhage led to the development of progressive paralysis, relieved only by operation. From the more deeply passing bullets a more or less oval opening resulted, in which both tables were freely comminuted and displaced. These cases differed from the typical gutter fracture only in length and outline, and the nature of the accompanying intra-cranial lesion was identical, while in the latter particular they differed much from fractures in which the impact of the bullet was direct, in spite of a near resemblance in the appearances in the osseous defect. I saw one instance in which a circular fissure about 1-1/2 inch from the actual opening of entry surrounded the latter, the area of bone within the circle being somewhat depressed, though radial fissures were absent. In several of these cases fragments of lead were either found on the fractured surface of the bone or within the cranial cavity, showing that the bullets had undergone fissuring of the mantle, or had actually broken up on impact. _Gutter fractures._--The nature of the injury to the bones in these is best illustrated by a series of diagrams of sections such as are shown below. [Illustration: FIG. 64.--Gutter Fracture of first degree. The drawing does not show well the small fragments of bone usually carried from the margins of the depression by the bullet.] In the most superficial injuries the outer table was grooved and depressed, usually with loss of substance from small fragments directly shot away: these latter had either been driven through the wound in the soft parts, or remained embedded on the deep aspect of the enveloping scalp (fig. 64). In the less common variety the scalp was slit to a length corresponding with the injury to the bone, but more often oval openings in the skin existed at either end of the track. The inner table was practically never intact, but the amount of comminution naturally varied with the depth to which the outer table was implicated (fig. 65 _A_, and _B_). The following is an illustrative example of this degree, and also emphasises the consequences which may follow primary non-interference. [Illustration: FIG. 65.--Diagrammatic transverse sections of varying condition of bones in Gutter Fractures of the first degree. _A._ With no loss of substance. _B._ With comminution.] (53) _Superficial gutter fracture in parietal region. Convulsive twitchings. Secondary paralysis._--Wounded at Modder River. Range, 400 yards. A scalp wound 3 inches in length ran vertically downwards, commencing 1 inch from the median line, and situated immediately over the upper third of the right fissure of Rolando. The patient was unconscious for several hours after the injury, and later suffered with severe headache, and twitchings in the left shoulder and arm. The wound healed, but a well-marked groove was palpable in the bone beneath, and the twitchings persisted. The latter came on about every twenty minutes, and loss of power in the left upper extremity, and to a less degree in the lower, developed. The memory was defective, and the patient suffered at times with headache. The pupils were equal but sluggish in action. No changes were discovered in the fundus beyond a well-developed myopic crescent at the lower and outer part of the left disc (Mr. Hanwell). The twitchings became more frequent and latterly were accompanied by somewhat severe muscular contractions in the upper extremity, while the loss of power in the lower extremity became more marked. Headache was also more troublesome. The patient throughout refused any operation, saying he would rather go home first, and at the end of a month he left for England. In the deeper injuries more and more of the outer table was cut away, and the inner became gradually more depressed, fractured, or comminuted (fig 66). [Illustration: FIG. 66.--Gutter Fracture of the second degree. Perforating the skull in the centre of its course. External table alone carried away at either end.] Bevelling at the expense of the outer table at both entry and exit ends of the course existed, but in either case a portion of the inner table was also detached and depressed. Sometimes the depressed portion of the inner table was mainly composed of one elongated fragment; this was either when the bullet had not implicated a great thickness of the outer table, or had passed with great obliquity through especially dense bone (see fig. 70). When the bullet had passed more deeply the inner table was comminuted into numberless fragments. I have frequently seen 50 or 60 removed. Where such tracks crossed convex surfaces of the skull, the two conditions were often combined; thus at one portion of the track, usually the centre, the comminution was extreme, while at either end a considerable elongated fragment of inner table was often found, the latter perhaps more commonly at the distal or exit extremity (fig. 67). [Illustration: FIG. 67.--Diagrammatic transverse sections of complete Gutter Fracture. _A._ External table destroyed, large fragment of internal table depressed. (Low velocity or dense bone.) _B._ Comminution and pulverisation of both tables centre of track. _C._ Depression of inner table (low velocity)] The nature of the injury to the bone when the flight of the bullet actually involved the whole thickness of the calvarium was comparable to that seen in the case of the long bones when struck by a bullet travelling at a moderate rate (see plate XIX. of the tibia, or what is illustrated in the case of the pelvis in fig. 55). In point of fact, a clean longitudinal track appeared to have been cut out. The length of these tracks naturally depended upon the region of the skull struck. When a point corresponding to a sharp convexity, or a sudden bend in the surface, was implicated, an oval opening of varying length in its long axis was the result; when a flat area, as exists in the frontal or lateral portions of the skull, was the seat of injury, a long track was cut. _Superficial perforating fractures._--These formed the next degree; the chief peculiarity in them was the lifting of nearly the whole thickness of the skull at the distal margin of the entry, and the proximal edge of the exit, openings; the flatter the area of skull under which the bullet travelled the more extensive was the comminution. In some cases nearly the whole length of the bone superficial to the track would be raised; in fact, the bullet having once entered, the force is applied from within in exactly the same way that it operates on the inner table in the gutter fractures. A corresponding injury is met with in the case of the bones of the extremities (see fig. 57 of the tibia), and again the resemblance between these injuries of the skull and such perforations of the long bones as are illustrated by skiagrams Nos. III. and XXIII. of the clavicle and fibula is a close one. [Illustration: FIG. 68.--Superficial Perforating Fracture. Illustrating lifting of roof at both entry and exit openings] I will add here a case of coexistent gutter fracture and perforating wound of the skull, the conditions of the bone in which will illustrate the behaviour of the outer and inner tables respectively, when struck with moderate force. [Illustration: FIG. 69.--Diagrammatic longitudinal section of Fracture shown in fig. 68] [Illustration: FIG. 70.--Fragment forming the main part of the floor of Gutter Fracture in the squamous portion of the temporal bone. (Low velocity, hard bone)] (54) Wounded at Thaba-nchu. Guedes bullet. _Entry_ behind left ear, just above posterior root of zygoma; gutter fracture; bullet retained within skull. Above and corresponding to right frontal eminence there was a hæmatoma, beneath which a loose fragment of bone was readily palpable. When brought into the Field hospital, twenty-four hours after the injury, the man appeared to understand when spoken to, but made no answers to questions. The urine was passed unconsciously, the bowels were confined. He was drowsy, the pupils widely dilated, the pulse 68, of good strength, and the temperature 104°. He slept well the following night and midday there was little change, except that the pupils acted to light, and the pulse had risen to 88, becoming dicrotic and small. The temperature was 103°, the tongue furred and dry, but he was lying with the mouth wide open. At 2 P.M. the wound was explored. The entry led down to a typical gutter fracture in the squamous portion of the temporal bone, at the point of junction of the vertical with the horizontal part; the floor of the gutter had been displaced inwards as a single fragment (fig. 70). A flap was raised in the frontal region, where a scale of outer table (fig. 71), clothed with diploic tissue, was found loose. Beneath this a puncture on the frontal bone, about corresponding in size to the bullet, was discovered. This opening was enlarged, and a bullet detected and removed. The bullet was a Guedes, with no marks of rifling, and was in no way deformed. At least a square inch of the right frontal lobe was pulped, so that the bullet lay in a cavity. The patient improved somewhat during the next two days, and on the third took a 16 hours' journey to Bloemfontein, where Mr. Bowlby (who was present at the operation) kindly took him into the Portland Hospital. The pulse gradually rose to 112, the temperature remained on an average from 102° to 103°, the respiration rose to 36, the face became somewhat livid, and on the sixth day death occurred rather suddenly, apparently from respiratory failure. For two days before his death the patient sometimes asked for food, &c.; there was occasional twitching of the left angle of the mouth, and, when the posterior wound was manipulated, some twitching of the fingers of the left hand. When the wound was dressed on the fourth day, there were breaking-down blood-clot and signs of incipient suppuration. Mr. Bowlby made a _post-mortem_ examination, and found considerable pulping of the tip of the right frontal and left temporo-sphenoidal lobes, and a thick layer of hæmorrhage extending over the whole base of the brain. [Illustration: FIG. 71.--Scale of outer table of Frontal Bone and Diploë. Exact size, from fracture shown in fig. 72] [Illustration: FIG. 72.--Perforating Fracture of Frontal Bone from within Separation of plate outer table. (Low velocity.) 1/2] The injury to the _cranial contents_ varied with the degree of bone injury. Hæmorrhage on the surface of the dura may in rare instances have been the sole gross lesion; I never met with such a condition, however. In all the cases in which comminution had occurred, some laceration of the dura, even if not more than surface damage or a punctiform opening, had resulted. In the more serious gutter fractures an elongated rent of some extent usually existed. In the perforating fractures two more or less irregular openings were the rule. The amount of hæmorrhage, even if the venous sinuses were implicated, was on the whole surprisingly small, when the cases were such as to survive the injury long enough to be brought to the Field hospital. I never saw a typical case of middle meningeal hæmorrhage, although many fractures crossing the line of distribution of the large branches came under observation. Case 60, p. 274, illustrated the fact that the osseous lesions of lesser apparent degree are sometimes the more to be feared in the matter of hæmorrhage, as compression is more readily developed. The degree of injury to the brain depended on the depth of the track, the resistance offered by the bones of any individual skull, the weight of the patient, but chiefly on the degree of velocity retained by the bullet. It was sometimes slight and local as far as symptoms would guide us; but in the majority of cases out of all proportion to the apparent bone lesion, if the range was at all a short one. Cases illustrative of these injuries are included under the heading of symptoms. It will be, of course, appreciated that the coarse brain lesions under the third heading differed in localisation and in extent alone, and in no wise in nature, from those observed in the two preceding classes. The damage consisted in direct superficial laceration and contusion, and beyond the limits of the area of actual destruction, abundant parenchymatous hæmorrhages more or less broke up the structure of the brain, such hæmorrhages decreasing both in size and number as macroscopically uninjured tissue was reached. No opportunity was ever afforded of examining a simple wound track in a case in which no obvious cerebral symptoms had been present. IV. _Fractures of the base._--In addition to the above classes, a few words ought to be added regarding the gunshot fractures of the base of the skull. These possessed some striking peculiarities; first in the fact that they might occur in any position, and hence differed from the typically coursing 'bursting' fractures we are accustomed to in civil life as the consequence of blows and falls, and consequently were often present without any of the classical symptoms by which we are accustomed to locate such fissures. Secondly, the peculiar form was not uncommon in which extensive mischief was produced from within by direct contact of a passing bullet. As far as could be judged from clinical symptoms, indirect fractures of the base such as we are accustomed to meet in civil practice in connection with fractures of the vault were decidedly rare, and, as has already been mentioned, ocular evidence of extensive fissures extending from perforating wounds of the vertex was wanting, except in the extreme cases classed under heading I. For these reasons I am inclined to regard them as uncommon. Direct fractures of the base, on the other hand, were of common occurrence, especially in the anterior fossa of the skull. These might be produced either from within, the most characteristic form of gunshot injury, or from without. The fractures from within were often simple punctures of the roof of the orbit or nose. Punctured fractures of the roof of the orbit caused little trouble as far as the cranium was concerned, but the orbital structures often suffered severely. I saw one or two very severe comminutions of the roof of the orbit caused by bullets which had crossed the interior of the skull; in one case the whole roof was in small fragments, while the damage in others was not greater than chipping off some portion of the lesser wing of the sphenoid. The roof of the orbit again was sometimes very severely damaged by bullets which first traversed that cavity itself; thus in one case which recovered, the bullet passed transversely, smashing both globes, and fracturing the roof of both orbits and the cribriform plate so severely as to lacerate both dura-mater and brain, portions of the latter being found in the orbit on removal of the damaged eyes. Fractures of the middle and posterior fossæ were met with far less frequently, partly I think because vertical wounds passing from the vertex to the base in these regions were with few exceptions rapidly fatal, and partly from the fact that the occipital region, being ordinarily sheltered from the line of fire, was rarely exposed to the danger of direct fracture from without. As an odd coincidence I may mention that in my whole experience during the war I only once saw bleeding from the ear as a sign of fracture of the base, apart from direct injuries to the tympanum or external auditory meatus. _Symptoms of fracture of the skull, with concurrent injury to the brain._--These consisted in various combinations of the groups of signs indicative of the conditions of concussion, compression, cerebral irritation, or destruction. Although the symptoms possessed no inherent peculiarities, yet certain characteristics exhibited served to illustrate the fact that, as a result of the special mechanism of causation of the injuries, the type deviated in many ways from that accompanying the corresponding injuries of civil practice. The characters of the external wounds will be first considered, followed by some remarks concerning the symptoms attendant on the different degrees and types of lesion, the symptoms special to injuries to different regions of the head, and on the subsequent complications observed. In the simplest injuries the type forms of entry and exit wound were found, and it has already been observed that in these, if symmetrical, considerable difficulty existed in discriminating between the two apertures. This is to be explained by the fact that the arrangement and structure of the scalp are identical in corresponding regions; hence the only difference in the conditions of production of the entry and exit wounds exists in the absence of support to the skin in the latter. The granular structure of the hairy scalp is opposed to the occurrence of the slit forms of exit, hence the openings were usually irregularly rounded. Any increase of size in the exit wound in the soft parts due to the passage of bone fragments with the bullet, was equalised in that of entry by the fact that the latter, as supported by a hard substratum, was usually larger than those met with in situations where the skin covers soft parts alone. In some cases of gutter fracture the wounds of entry were large and irregular, as a result of upward splintering of the bone at the distal margin of the aperture of entry in the skull, and consequent laceration of the scalp. Again, on the forehead very pure types of slit exit wound were often met with in the position of the vertical or horizontal creases. With higher degrees of velocity on the part of the bullet and consequent comminution at the aperture of exit in the bone, the scalp was more extensively lacerated, and large irregular openings in the soft parts, often occupied by fragments of bone and brain pulp, were met with. It is well to repeat here, however, that the presence of brain pulp in a wound by no means necessarily indicated the aperture of exit, for it was sometimes found in the entry opening also. In the most severe cases, such as are included in class I., the exit wound often possessed in the highest degree the so-called 'explosive' character. From an opening in the skin with everted margins two or more inches in diameter a mass of brain débris, bone fragments and particles of dura-mater, skin, and hair, bound together by coagulated blood, protruded as a primary hernia cerebri if the patient survived the first few hours after the injury. In other cases of the same class the actual opening was smaller, but the whole scalp was swollen and oedematous, sometimes crackling when touched from the presence of extravasated blood in the cellular tissue, while firm palpation often gave the impression that the head consisted of a bag of bones over a considerable area. Gutter fractures of the scalp were sometimes situated beneath an open furrow, gaping from loss of substance, or beneath a bridge of skin; in the latter case they were usually palpable. Simple punctures were also usually palpable, but the smallness of the openings sometimes rendered their detection more difficult than might be assumed. I never saw a case in which the skull escaped injury when the bullet struck the scalp at right angles, but the frequency with which Mauser bullets were found within the helmets of men would suggest that this must have sometimes occurred. A case of injury to the external table alone has been described (p. 243). An illustration of the next degree of injury is afforded by the following:--A bullet lodged in the centre of the forehead, the point lying within the cranial cavity, while the base projected from the surface: this patient suffered but slight immediate trouble, so little, indeed, that he merely asked his officer to remove the bullet for him, as it was inconvenient. The bullet was subsequently removed in the Field hospital. In a few cases the bullet entered the skull and was retained, when only a single wound was found. Such cases are described in Nos. 54 and 68, where the position of the bullet was determined by palpable fractures beneath the skin. With regard to the retention of bullets, however, in small-calibre wounds, it was always necessary to examine the other parts of the body with great care, and to ascertain, if possible, the direction from which the wound was received, as an exit was often found some distance down the neck or trunk. Again the possibility of the opening having been produced by glancing contact had to be considered. In cases which survived the injury on the field, free hæmorrhage, as in wounds of other regions, was rare, and although general evidence of loss of blood was often noted in patients brought in, progressive bleeding was seldom observed. Again, when the wounds were explored, the amount of blood, although considerable, was usually not more than sufficed to fill up the space consequent on the loss of brain tissue. This was especially striking when large venous sinuses, as the superior longitudinal, were involved in the injury. None the less, hæmorrhage at the base of the brain was, I believe, responsible for early death in many of the severe cases, especially when the wounds were near the lower regions of the skull. Escape of cerebro-spinal fluid was not so prominent a feature as might have been expected, considering how freely the arachnoid space was opened up in many cases. I think this was usually checked by early coagulation of the blood, and later by adhesions. It must be remembered also that extensive wounds were most common on the vertex, or at any rate over the convex surface of the brain, while fractures of the middle fossa were usually rapidly fatal. _Concussion._--Cases exhibiting symptoms of pure uncomplicated concussion were distinctly rare, as would be expected from the mechanism of the injuries. On the other hand, symptoms of concussion formed the dominant feature of all severe cases. The symptoms in many instances consisted in great part in transitory signs of the so-called 'radiation' type, such as are seen in destructive lesions where the signs of nervous damage rapidly tend to diminish and localise themselves. As to the causation of the 'radiation' symptoms, it is difficult to discriminate the effects of neighbouring parenchymatous hæmorrhages from those of local vibratory concussion of the nervous tissue. The local character of the signs seems, however, to point to causation by molecular disturbance, resulting from the conduction of forcible mechanical vibration to the brain tissue rather than to upset in the intra-cranial pressure. Again the limited nature of the paralysis observed, sharply defines it from the general loss of power accompanying ordinary cases of concussion of the brain. The similarity of the phenomena to those described in other parts of the body under the heading of 'local shock' is sufficiently obvious. The following instance well exemplifies the condition in question: (55) Wounded at Spion Kop. A scalp wound 3 inches in length crossed the left parietal bone nearly transversely, starting 1-1/2 and ending 2 inches from the median line: the centre of the wound corresponded with the position of the fissure of Rolando. The patient was struck at a distance of fifty yards while kneeling; he fell and remained unconscious an hour and a half. Right hemiplegia without aphasia followed. The wound was cleansed and sutured, and in three days both arm and leg could be moved, after which time the man improved rapidly. Three weeks later when I saw him at Wynberg there was still comparative weakness of the right side, but beyond some neuralgia of the scalp, the man considered himself well. No groove could be detected on the bone on palpation. (This case offers a good example of the ease with which bone injury may be overlooked. The man came over to England 'well;' but while on furlough, two pieces of bone came away spontaneously. He is now again on active service.) _Compression._--Equally rare was it for pure symptoms of compression to be exhibited. This depended on two circumstances: first, the rarity of injuries giving rise to meningeal hæmorrhage; secondly, the fact that in nearly every case a more or less extensive destructive lesion was present, at the margins of which less completely destroyed tissue remained, capable of giving rise to symptoms of irritation. Again, as we have seen, free hæmorrhage into, or from the walls of, the cavities produced in the brain was not a marked feature, and beyond this the large defect in the cranial parietes was calculated to render a high degree of compression impossible. As the most serious head injuries presented a remarkable similarity in their symptoms, I will shortly summarise their common features. Every degree of mental stupor up to complete unconsciousness was met with, but in some instances where the pulse, respiration, and general bodily condition pointed to speedy dissolution, the patients answered rationally often between moans or cries indicative of pain. Widespread paralysis often existed, but this was seldom completely general; more commonly it was combined with extreme restlessness of the unparalysed parts, or sometimes, even when the whole of one hemisphere was tunnelled, and in all probability widely destroyed, restlessness was the only symptom. In some cases twitching of the features or the limbs or severe convulsions were superadded. The pupils were rarely unequal, and at the stage in which these patients were first seen were usually moderately contracted. Wide dilatation was uncommon throughout. The pulse was with very few exceptions slow, sometimes irregular. In some instances, when the wounds had been thought suitable for exploration, the slow pulse was altered after operation to a rapid one, and death usually quickly supervened. Respiration was irregular, sometimes sighing; in the late stage often of the Cheyne-Stokes type; actual stertor was exceptional, but the respiration was often noisy. The temperature was often raised from an early stage to 99° or 100°, and if the patient survived a day or two, it often rose to 103° or 104°. How far the secondary rise depended on sepsis it was not always easy to determine. The urine was usually retained. Cases presenting the above characters were usually those suffering from lesions such as are described in class I., and mostly died in twenty-four to forty-eight hours. The correspondence of the train of symptoms with those due to combined brain destruction and severe concussion is at once apparent. To illustrate the nature of the symptoms in patients suffering from the less extensive forms of injury, such as those included in classes II. and III. under the heading of anatomical lesion, the relation of a short series of histories will be advisable. I may first premise, however, that the special characteristics of these were in some instances the almost entire absence of primary symptoms of gravity; in others general symptoms of a severity out of apparent proportion to the external lesion; while in all destructive lesions, very widely distributed radiation symptoms developed, often disappearing with great rapidity. The symptoms consisted in those of concussion, irritation, local pressure, and actual destruction. The symptoms of concussion were either general, and then usually transient, or local paralysis of the radiation variety, which also rapidly improved. Signs of irritation consisted in irritability of temper, drowsiness, closure of the eyes and objection to light, contracted pupils sometimes unequal, a tendency to the assumption of the flexed position at all the joints, twitchings, and sometimes convulsions. Sometimes these appeared early as a direct result of mechanical irritation from bone fragments or blood-clot; sometimes only in the course of a few days, as a result of irritation of parts recovering from the radiation effects which had prevented earlier nervous reaction. Possibly in some cases the symptoms of irritation depended upon an increase in the amount of hæmorrhage, and in others upon the development of local inflammatory changes. Local pressure, or actual destruction of brain tissue, was evidenced by temporary paralysis in the former, permanent loss of function in the latter, condition. Fractures of the anterior fossa of the skull were attended by very marked evidence of orbital hæmorrhage, as subconjunctival ecchymosis (rarely pure), increased tension, and proptosis. Injuries to the cranial nerves at the base, with the single exception of lesion of the optic nerves, which was not rare, were in my experience uncommon in the hospitals--a fact pointing to the very fatal nature of direct basal injuries, except in the anterior fossa of the skull. Signs indicative of injury to the olfactory lobe were occasionally observed. I should, perhaps, again insist here on the rarity with which acute diffuse septic infection occurred in cases of these degrees of severity, also on the fact that interference with the wounds in the way of secondary exploration, even when they were manifestly the seat of local infection, was followed almost without exception by good immediate results; and, lastly, that when suppuration did occur, it was usually strictly local in character. The influence of the climate of South Africa and our surroundings has already been discussed, but whether climate, condition of the patients, or peculiarity in the nature of causation of the wounds was responsible, in no series of cases was the absence of acute inflammatory troubles more striking than in this one of brain injuries. Frontal injuries were those most frequently unaccompanied by primary symptoms of severity; slowing of the pulse--this often fell to 40--and occasional irregularity, were almost the only constant signs of cerebral damage. Some patients temporarily lost consciousness, others rose at once and walked to the dressing station, and in few cases was any psychical disturbance noted in the early stages. I think, however, it may be affirmed that frontal injuries, accompanied by trivial signs, resulted without exception from the passage of bullets travelling at a low rate of velocity. Thus in several of the instances here related the patients at the time of reception of the wound were under the impression that they were entirely beyond the range of fire, and in one, in which well-marked signs of concussion followed, the bullet, which had traversed the head, retained only sufficient force to perforate the skin of the neck and bury itself in the posterior triangle without even fracturing the clavicle, against which it impinged. In men struck at a shorter range, signs of concussion, often followed by transient radiation signs of injury to the parietal lobe, were common. These signs were, I think, not as a rule due to surface hæmorrhage, since they were of a purely paralytic nature and not irritative. Several cases with partial or complete hemiplegia, hemiplegia and aphasia, or facial paralysis are recorded below. (56) _Frontal injury_.--Wounded at Magersfontein. In prone position when struck, distance 700 to 800 yards. _Entry_ (Mauser), at the margin of the hairy scalp above and to the left of the frontal eminence; course, through anterior third of left frontal lobe, roof of orbit, obliquely across line of optic nerve, inner wall of orbit, nose, right superior maxilla piercing alveolar process, and passing superficial to inferior maxilla: _exit_, one inch anterior to angle of jaw. The bullet again entered the posterior triangle of the neck, struck the right clavicle, and turned a somersault, so that its base lay deepest in the wound. The patient was unconscious for a short time, suffered with general headache and giddiness, and was somewhat irritable. On the third day the pulse was 70, temperature normal, and he was sent to the Base. There was considerable proptosis, oedema and discoloration of the eyelid, and subconjunctival ecchymosis, but the movements of the eyeball could be made and light could be distinguished. The sense of smell was apparently absent. A week later the headache was gone, the pulse numbered 80 to 90, the temperature was normal, he slept well, sat up in bed and smoked, took his food well, and exhibited no cerebral symptoms. He could detect the smell of tobacco, but not as a definite odour. No further symptoms were noted, the sense of smell returned, the swelling of the eyelid and proptosis decreased, but the upper lid could not be raised. When the lid was drawn up, there appeared to be vision at the margins of the field with a large central blind spot. The patient left for England at the end of a month apparently well. (57) _Gutter fracture of frontal bone._--Wounded at Paardeberg. _Entry_ (Mauser), 3/4 of an inch within the margin of hairy scalp above outer extremity of right eyebrow; gutter fracture; _exit_, 2 inches nearer middle line, at the same distance from the margin of the hairy scalp. The patient was knocked head over heels, his main feeling being a sense of dulness in the right great toe. He sat up and got a first field dressing applied, then lay down, but as he was still under fire, he retired 1,000 yards to the collecting station; here he dressed some patients, and later mounted an ambulance wagon and was driven to the Field hospital. The next day he helped with the work of the hospital, amongst other things controlling the artery during an amputation of the arm. He then took a three days' and nights' journey to Modder River in a bullock wagon, during which journey he had a fit, which was general, the thumbs being turned in and a wedge being necessary between the teeth to prevent him biting his tongue. On the sixth day the wound was examined, and between this and the tenth day he had several fits of the same nature as the first, accompanied by stertorous breathing and profuse sweating. On the tenth day Mr. Cheatle opened up the wound and removed numerous fragments of bone, leaving a clean gutter 2 inches by 3/4 of an inch. After the operation no further fits occurred, and eight days later he was conscious, but was excitable and talked at random. On the twentieth day he arrived at the Base after 30 hours' railway journey (623 miles). He was then quite rational, but unable to make any demands on his memory and very sensitive to noise; at times he wandered in the evenings and his temperature rose as high as 100°. The wound was open and granulating, the floor pulsating freely. Three weeks later the wound was still open, and the skin dipped in at the lower margin. The mental condition was much improved, although attempts at giving a history of his case were obviously tiresome. The wounds in the leather headband of this patient's helmet were interesting, the round aperture of entry in the exterior of the helmet being followed by a starred exit aperture in the leather band, the second entry opening in the leather band being again circular, and the external opening in the puggaree a transverse slit. (58) _Transverse superficial perforating frontal injury._--Wounded at Graspan. Aperture of _entry_ (Lee-Metford), at upper and outer part of left frontal eminence; _exit_, at margin of hairy scalp over outer third of right eyebrow. On the second day the patient complained of giddiness and headache; the pulse was 60. He was then walking about. The wounds were explored and typical entry and exit apertures discovered in the frontal bone from which cerebral matter was protruding. Both openings were enlarged (Mr. S. W. F. Richardson) with Hoffman's forceps, and a considerable number of splinters of the inner table were removed from the aperture of entry. The headache gradually passed off, but there was throbbing about the scar, and pulsation was visible for some three weeks, after which no further symptoms were observed. (59) _Oblique frontal gutter fracture._--Wounded at Magersfontein. _Entry_ (Mauser), 1/2 an inch to right of median line of forehead, 3/4 of an inch from the margin of the hairy scalp; _exit_, about 3/4 of an inch anterior to the lower extremity of the right fissure of Rolando. Weakness of left facial muscles, especially of angle of mouth. No further motor symptoms. Wounds explored (Mr. Stewart); numerous fragments of bone and some pulped cerebral matter were removed. Patient developed no further signs; the paralysis, although improved, did not completely disappear. The man a year later was still on active duty, the paralysis almost well, and no further ill effects of the injury remained. In the fronto-parietal or parietal regions, signs of damage to the cortical motor area were seldom absent, sometimes evanescent, at others prolonged. In some cases the signs were permanent and followed by evidence of local sclerosis. The motor area on both sides of the brain was sometimes implicated; thus in a child shot at Kimberley the bullet entered in the right frontal region, and emerged to the left of the line connecting bregma and inion a little behind its centre. Paralysis of both lower extremities resulted, power rapidly returning in the right, while incomplete paralysis persisted in the left. In only one instance (see case 73, p. 292) was any permanent sensory defect observed, and the mental condition of this patient would have certainly suggested a functional explanation for its presence, had it not been for the accompanying inequality in the axillary surface temperatures. In a second case (No. 67) blunting of sensation followed a definite lesion of the inferior parietal lobule. In this instance an occipital lesion was associated with the parietal. (60) _Parietal gutter fracture._--Wounded at Magersfontein. A scalp wound 3 inches in length ran transversely across the right parietal bone at the level of the lower third of the fissure of Rolando. A second wound of entry was found crossing the third dorsal spine; the bullet was retained and was palpable over the right scapula. There was left facial paralysis, weakness and numbness of both upper extremities, especially of the left, and some difficulty in swallowing. The man was sent to the Base, where he arrived on the fourth day. The symptoms had then become much more marked, consciousness was incomplete, and articulation slow and imperfect. There was complete left hemiplegia, and deviation of the tongue to the right. The pulse was 40. An exploration (Mr. J. J. Day) showed that an oval plate of the outer table of the parietal bone had been struck off. A trephine was applied to the exposed diploë and a crown of bone removed; considerable comminution of the inner table had occurred, several large fragments having perforated the dura-mater. The latter did not pulsate; it was therefore freely incised, and many more fragments of bone and a large quantity of blood-clot removed. The first effect of the operation was slight, but ten days later rapid improvement commenced, the first sign being acceleration of the pulse, which rose to 70. On the eighteenth day the original symptoms still remained to a diminished extent, but a fortnight later there remained traces of the facial weakness only, and there was little difference in the grip of the two hands. The patient was shortly afterwards sent home. Ten months later he returned to South Africa on active service. (61) _Fronto-parietal gutter fracture._--Wounded at Graspan. _Entry_ (Mauser), 1 inch within the margin of the hairy scalp, 1/2 an inch to the left of the median line; _exit_, 3-1/2 inches posterior in same line. Complete right-sided hemiplegia. The wounds were explored on the fourth day (Major Moffatt, R.A.M.C.) and a gutter fracture involving the frontal and parietal bones exposed. The dura-mater was lacerated and brain matter from the frontal lobe escaped freely. A large number of bone fragments were removed. On the fourth day after the operation, the patient became unconscious with right-sided twitchings, but rapidly improved, and at the end of three weeks, except for slight headache, he was well, the power of the right side being good. Ten months later he rejoined his regiment in South Africa, no apparent ill effects remaining. (62) _Fronto-parietal perforating fracture._--Wounded at Magersfontein. _Entry_, within the margin of the hairy scalp; _exit_, behind and below the left parietal eminence, the track crossing about the centre of the fissure of Rolando. Right hemiplegia, the lower half of the face only being involved. The wounds were explored and a large number of fragments of bone and a quantity of pulped cerebral matter removed. Six days later the hemiplegia persisted, speech was slow, headache was troublesome and the pulse not above 45. After this, gradual improvement took place, and a month later the lower extremity and face had regained good power. The upper extremity remained flaccid and paralysed, except for some slight power of movement of the shoulder. (63) _Fronto-parietal perforating fracture._--Wounded at Magersfontein. _Entry_ (Mauser), 2-1/2 inches from the median line, 3-1/2 inches from the occipital protuberance; _exit_, 3/4 of an inch from the median line, 4-1/2 inches from the glabella; sanious fluid escaped from both ears. There was left facial paralysis, complete paralysis of the left upper extremity, and partial paralysis of the left lower extremity. The patient was deaf, drowsy, and the pulse 45. Exploration showed the entry wound to be in the parietal, the exit to involve both parietal and frontal bones. The openings were enlarged, and a number of fragments of bone, together with pulped cerebral matter and blood-clot, were removed. The wound healed, except at the front part, where a small prominence suggested a hernia cerebri. The patient improved slowly; fourteen days after the operation he could hear well, and the flow from the ears had ceased. The facial weakness was slight, the upper extremity was still powerless, but he could move the lower and draw it up in bed. At the end of six weeks the wound had healed, and he was got up and dressed. At the end of two months he was well enough to be sent home; there was only a trace of facial weakness; the right upper extremity, however, was powerless and slightly rigid, occasional twitchings occurring in it. Considerable power had been regained in the lower extremity, so that the patient could walk with help, but foot-drop persisted; the gait was spastic in character, the reflexes were much exaggerated, and there was marked clonus. The patient was sensible, but his manner suggested some mental weakness. Both the openings in the skull were closed by very firm material, apparently bony. This patient became a Commissionaire some ten months later. His mental condition is normal, and loss of memory seems confined to the events immediately following the injury. The lower extremity has improved, but the upper is useless. (64) _Parietal injury: retained bullet._--Wounded at Paardeberg. Aperture of _entry_ (Mauser), 1 inch diagonally below and anterior to left parietal eminence. No exit. The patient was trephined by the surgeons of the German ambulance at Jacobsdal. Sixteen days later he arrived at the Base. A circular pulsating trephine opening was then to be felt beneath the flap, but no information was forthcoming as to the bullet. The patient could speak, but lost words and the gist of sentences; he could remember nothing as to himself since the day of the injury. There was right facial weakness; he could not close the right eye or whistle, but there was little apparent want of symmetry; there was weakness in the grip of both hands, more marked on the right side; both lower extremities could be moved. The reflexes were normal, although the left limb was slightly rigid. The pupils were equal, reflex normal; slight nystagmus. Pulse 72, small and regular. Temperature normal. Rapid improvement followed. During the fourth week the temperature rose to 103°, and remained elevated for six days, but no local or general signs appeared; at the end of five weeks there was little evidence of the paralysis remaining. The patient was discharged from the service on his return home. In the upper part of the occipital region glancing or superficial injuries were comparatively favourable; those near the base, especially if perforating, were very dangerous. Two such cases are referred to elsewhere. Case 69 is included as the only example of cerebellar injury I happened to see who lived any appreciable time after the accident. The main interest in these cases centres in the defects produced in the area of the visual field. I am extremely indebted to my colleague, Mr. J. H. Fisher, who has kindly determined this for me in three of the following cases. It will be noted that in two instances the injury was to the left occipital lobe. In these the resulting hemianopsia was of the pure lateral homonymous character, and in both the visual symptoms were accompanied by a certain degree of amnesic aphasia (65 and 68). In 65 the injury was definitely unilateral, and at the time of the operation I decided that at least an inch and a half of the posterior extremity of the left occipital lobe was totally destroyed. In 68 the lesion was probably confined to the left lobe, but it is impossible to exclude slight injury to the right lobe also. In this instance amnesic aphasia was a far more marked symptom than in 65, and the position of the lesion suggested damage both to the visual and auditory word centres. Cases 66 and 67 are instances of damage to both occipital lobes. In 66, although the wound was a glancing one, and did not perforate, it was so near the median line, and accompanied by such severe damage to the bone, that a symmetrical lesion of the cuneate and precuneate lobules of both right and left sides is to be inferred. In 67 the great longitudinal fissure was traversed by the bullet obliquely. It is of great interest to observe that in each of these cases the lesion of the visual field was a horizontal one and affected the lower half in place of assuming a lateral distribution. In all four cases the primary effect of the occipital injury was the same--viz. absolute blindness--while the return of vision in each was of the nature of the dawning of light. I regret that I am unable to furnish any detail as to increase of the field of vision in the progress of the cases, but circumstances rendered continuous observation of the patients impossible. In each case deafness was apparently the direct result of concussion of the ear on the side corresponding to the wound. Deafness of the opposite ear was never noted. In case 67 some general blunting of sensation was noted in the paralysed upper extremity, and in this patient, no doubt, injury to the inferior parietal lobule accompanied the occipital lesion. (65) _Injury to left occipital lobe._--Wounded at Belmont. A single transverse wound, 2 inches in length, extended across the occipital bone, 2 inches above the level of the external protuberance. When seen on the third day the wound was gaping and pulped cerebral matter was found in it. The patient was very drowsy, lying with closed eyes, and complaining of great coronal and frontal headache. He could distinguish light and darkness, but not persons. Total blindness immediately followed the injury, persisting some three days, and the patient spoke of return of sight as of the appearance of dawn. The pupils were equal, moderately dilated and acted to light, which was unpleasant to him. He was somewhat irritable and silent, but apparently rational. Temperature 99°. Pulse 56 full. Tongue clean. No sickness, no difficulty in micturition. Fifty-six hours after the injury the wound was opened up and cleaned, and an oval fractured opening about 3/4 by 1/2 inch was exposed 3/4 inch to the left, and 2 inches above the occipital protuberance. The margins of the opening showed several small fragments of lead attached to the bone. A 3/4-inch trephine was applied at the left extremity of the opening, and it was found that about a square inch of the internal table was comminuted and driven into the brain, together with several small fragments of lead. On introducing the finger, about 1-1/2 square inches of the occipital lobe were found to be pulped, and the finger could be swept across the tentorium. There was no sinus hæmorrhage (nor did the history suggest that hæmorrhage had ever been severe). The cavity was carefully sponged out, and the wound closed with a drainage aperture. Little change followed in the patient's condition, and on the sixth day he was sent to the Base hospital. Three weeks later the wound was firmly healed. The patient still complained of frontal headache, and wore a shade, as the light hurt his eyes and made them water freely. The pupils acted, but were wide; objects could be distinguished, and also persons. Otherwise, the man's condition was good: he began to get up, and at the end of six weeks returned to England. A year later the man was earning his living as a Commissionaire porter. He complains of giddiness when he stoops, or when he looks upwards, and at times he suffers much with headache both in the region of the injury and across the temples. There is a bony defect and slight pulsation at the site of the injury, but no prominence. When attempts are made to read the lines run together, and a dark shadow comes before his eyes. He speaks of the latter as still terribly weak. Speech is slow and somewhat simple, but he makes no mistakes as to words. Memory is bad for recent events. Mr. Fisher makes the following report as to the eyes: Pupils and movement of eyes normal in every respect. No changes in fundi. Vision, R. 5/12 with--0.5 5/6 L. 5/9 with--0.5 5/5 [Illustration: FIG. 73.--Right Visual Field, in case 65. Injury to left occipital lobe. Field for white. Test spot 10 mm. Good daylight. Right homonymous hemianopsia] [Illustration: FIG. 74.--Left Visual Field, case 65] There is therefore practically full direct vision. Though the man chooses a concave glass he is not really myopic. There is typical right homonymous hemianopsia; the answers, when tested with the perimeter, are quite certain, and the fields absolutely reliable. The man's statements confirm the condition; he is aware of his inability to see objects to his right-hand side, and is apt to collide with persons or objects on that side. The lesion is one of the left occipital cortex in the cuneate lobe and the neighbourhood of the calcarine fissure. The speech suggests a slight degree of aphasia. (66) _Injury to occipital lobes._--Wounded at Magersfontein while in prone position. Distance, 500 yards. He says he was never unconscious, but for two days was absolutely blind. His eyesight gradually improved, but headache was very severe, and sleeplessness nearly absolute. On the eighth day the wound, which was situated over the right posterior superior angle of the parietal bone, was opened up, and a number of fragments of bone and a quantity of pulped brain removed from a depressed punctured fracture, surrounded by an annular fissure, completely encircling it, 1-1/2 inch from the opening. The portion of brain destroyed was probably a considerable portion of the cuneate and precuneate lobules of both sides, as well as a portion of the first occipital convolution, and the superior parietal lobule of the right side. There was no evidence of injury to the superior longitudinal sinus in the way of hæmorrhage. After the operation the patient slept better, but still complained of headache, and when he arrived at the Base, the flap became oedematous, and the stitch holes and also the central part of the wound suppurated. The temperature rose to 101°. The wound was therefore re-opened, and a number of additional fragments of bone, some as deeply situated as 2 inches from the surface, were removed. Steady improvement followed, and at the end of a further three weeks the wound was healed, the headache had ceased, and there were no abnormal symptoms, except that light was unpleasant to the right eye, and the field of vision was manifestly contracted (Mr. Pooley). A year later the man was employed as a letter-carrier. He complains of headache at times, and on six occasions has had 'fainting fits.' He says that the latter commence with tremor, that his legs then give way and he falls. In a quarter of an hour he gets up, and feels no further inconvenience. Speech is perfect, there is no deafness. The bone defect is very nearly completely closed. Mr. Fisher reports as follows as to the vision. There is a high degree of hypermetropia in each eye, the R. has nearly 6.0 D and the L. about 5.0 D. With correction he gets practically full direct vision with each. [Illustration: FIG. 75.--Right Visual Field, in case 66. Injury to both occipital lobes. Field for white. Test spot 10 mm. Good artificial light. Defect in field complicated by functional symptoms] [Illustration: FIG. 76.--Left Visual Field, in case 66. Defect in lower half of field] The patient has been examined before, and has been informed that his vision quite incapacitates him from further service. He began by stating that he could not see on either side of him, but only straight in front; that he is apt to collide with people in walking, was nearly knocked down by a horse, and that his acquaintances accuse him of passing them unnoticed. The fields of vision are very small, but the loss is not typically in the temporal half of either. That of the right eye which we know as the spiral field, becoming more and more contracted as the perimeter test is continued, is what is found in functional cases; that of the left, however, shows a characteristic loss of the lower part of the field of vision, and agrees with the statement of the man that he can see the upper part of my face but not the lower when he looks at me. Such a loss agrees with a lesion involving the upper part of the cuneate lobe above the calcarine fissure. I feel satisfied that there is considerable loss in the right field also, but the functional element obscures its exact nature. The fundi, pupils, and ocular movements are all normal. (67) _Injury to occipital lobes and left motor and sensory areas._--Wounded outside Lindley (Spitzkop). Range within 1,000 yards. _Entry_, one inch within the right lateral angle of the occipital bone, external wound more than 1/2 an inch in diameter; _exit_, 2 inches from the median line, over the upper half of the left fissure of Rolando. Behind the wound of exit comminution of the parietal bone, extending back to the lambdoid suture, existed. I attributed this to oblique lateral impact by the bullet on the inner surface of the skull. The patient could afterwards remember being struck, but became rapidly unconscious. When brought into the Field hospital some five hours later the condition was as follows: Semi-conscious, can speak, apparently blind, pupils equal, of moderate size, do not react to light. Right hemiplegia. No sickness. Moans with pain in head. Passes water normally. Considerable hæmorrhage had occurred from each wound, the scalp was puffy, and the bones yielded on pressure over the left parietal bone, indicating considerable comminution. The night was so cold that no operation could be considered, so the head was partly shaved, the wounds cleansed, and a dressing applied. The next morning the Division marched at 5 A.M., and it was considered wise to leave the man at Lindley in the local hospital. [Illustration: FIG. 77.--Right Visual Field, in case 67. Injury to both occipital lobes. Field for white. Test spot 10 mm. Good artificial light. Defect in lower half of field] [Illustration: FIG. 78.--Left Visual Field, in case 67] No operation was performed there, but I heard later that the man recovered full consciousness at the end of five days, and at the end of a fortnight he commenced to see again. Six weeks later he travelled to Kroonstadt, thence to Bloemfontein, and thence to Cape Town and home to Netley. The paralytic symptoms meanwhile steadily improved. Seven months later his condition is as follows: Scarcely a trace of facial paralysis. Slight power of movement of arm, forearm, and fingers, but grip is very weak. Little power of abduction of the shoulder or of straightening the elbow. The latter movement is made with effort and in jerks. Sensation over the back of the arm is somewhat lowered, and is 'furry' at the finger tips. There is very little wasting of the muscles noticeable. Walks well, but with some foot-drop. Slight increase of patellar reflex. He says that he does not walk in the street with confidence, as he often feels as if omnibuses &c. were coming too near him. He is absolutely deaf in the right ear. The openings in the skull are closed, the occipital lies about halfway between the external auditory meatus and the external occipital protuberance, while the parietal still affords evidence of the earlier comminution, one fissure passing backwards as far as the lambda, and the whole surface is lumpy and uneven. The track through the brain no doubt involved a considerable extent of the outer aspect of the right occipital lobe and the cuneate lobule. It must also have crossed the great longitudinal fissure, and penetrated the left Rolandic region, just above its centre, probably involving the precuneate lobule, and a portion of the internal capsular fibres as well as the cortex on the left side. The deafness was probably due to concussion of the internal ear. Mr. Fisher has kindly furnished the following note regarding the vision. The pupils, movements, and fundi are quite healthy. There is good direct vision R. or L. 5/5 fairly, and together 5/5. The man complains he has lost his side sight, also the lower; he demonstrates the latter quite obviously with his hand, and says he has to repeatedly look down when walking. He thinks no improvement has taken place during the last month. The accompanying fields of vision show the loss quite characteristically. (68) _Injury to left occipital lobe._--Wounded at Paardeberg. _Entry_ (Mauser), through the lambdoid suture on the right side of the mid line. Bullet retained, but a palpable prominence behind the left ear suggested its localisation. The patient became at once unconscious and remained so for several days. He was completely blind; vision returned later, but only to a limited degree. There was complete loss of memory as to the events of the day. When admitted at Rondebosch into No. 3 General Hospital the condition was as follows: The field of vision is limited, and examination shows right homonymous hemianopsia. When any one comes into the tent the patient sees a shadow only until his bed is reached. When spoken to the patient 'thinks and thinks,' and then apologises for not answering, saying he will remember at some future time. He is absolutely unable to remember times, names, or localities, but places his hand to his head and appears to think deeply in the effort to recall them. Occasionally when you go into his tent he suddenly remembers something he has been trying to think of for some days, and will tell you. A fortnight later after an attack of influenza the patient was not so well, and vision was apparently becoming more impaired. An incision was made (Mr. J. E. Ker) so as to raise a flap the centre of the convexity of which was 2-1/2 inches behind the left external auditory meatus. A slight prominence and a fissure was discovered in the temporal bone, and over this a trephine was applied. On removal of the crown of bone the bullet was discovered with the point turned backwards (having evidently undergone a partial ricochet turn) on the upper surface of the petrous bone, just above the lateral sinus. The dura-mater was healed but thickened, and some clot upon its surface was removed. The wound healed per primam, and a rapid recovery was made. Ten days later a running water-tap was able to be detected 120 yards from the tent door. The hemianopsia however persisted. The following letter, dictated by the patient to his wife, and sent to me, gives a clear account of his condition ten months later:-- I am pleased to say my memory is better than it was some time ago, though at times I am entirely lost and really forget all that I was speaking about. I also find that I often call things and places by their wrong names. I sometimes try to read a paper or book which I have to read letter by letter, sometimes calling out the wrong letter, such as B for D &c., and by the time I have read almost halfway through, I have forgotten the commencement. My sight is about the same. There is no improvement in the right eye, and the doctor at Stoke said that the left eye was not as it ought to be and might get worse. I ofttimes go to take up a thing, but find I am not near to it, though it appears to me so. I have no pain to speak of in the head, though at times a shooting pain. I have a continual noise in the left ear as if of a locomotive blowing off steam, and a deafness in the left ear which I had not before being wounded. I am extremely indebted to my friend Mr. J. Errington Ker for the notes of the above case, so successfully treated by him. (69) _Injury to occipital lobe._--Wounded at Modder River. Scalp wound in occipital region. Two days later on arrival at the Base the patient was extremely restless and in a condition of noisy delirium. The wound was explored (Mr. J. J. Day) and a vertical gutter fracture discovered 1/2 an inch above and to the left of the occipital protuberance. The gutter was 1-1/2 inch in length and finely comminuted, the dura wounded, and the left occipital lobe pulped. A number of fragments of bone (one lodged in the wall of, but not penetrating, the lateral sinus) and pulped brain were removed. No improvement took place in the general condition, but the patient lived twenty-two days, during which time he coughed up a large quantity of gangrenous lung tissue and foul pus. At the _post-mortem_ examination a wound track was found extending to the crest of the left ilium, where the bullet was lodged. The patient was no doubt lying with his head dipped into a hole scooped out in the sand (a common custom) when struck; the bullet then traversed the muscles of the neck, entered the upper opening of the thorax, where it struck the bodies of the second and third dorsal vertebræ, one third of the bodies of each of which were driven into an extensive laceration of the lung; it then grooved the inner surfaces of the eighth and ninth ribs, fractured the tenth and eleventh, and passing the twelfth traversed the deep muscles of the back to the pelvis. Beyond the injury to the occipital lobe, the cerebellum was found to be lacerated and extensively bruised and ecchymosed. _Complications._--_Hernia cerebri_ as a primary feature has already been mentioned as one of the peculiarities of some explosive wounds. In the later stages of the cases in which primary union did not take place the development of granulation tumours was often seen, sometimes in connection with slight local suppuration, sometimes over a cerebral abscess. In some cases a wound which had once closed reopened and a hernia developed. This sequence was chiefly of prognostic significance as an indication of intra-cranial inflammation, usually of a chronic character, and affecting rather the lowly organised granulation tissue formed in the cavity than the brain itself. When primary union of the skin flap and wound failed, the process of definitive closure of the subjacent cavity was always a very prolonged one, and it was in such cases that a great proportion of the so-called herniæ developed. _Abscess of the brain._--Local abscesses formed in a considerable proportion of the cases where serious damage to the brain had occurred, in whatever region this happened to be. I never saw one develop in cases where primary union had taken place, even when bone fragments had not been removed; neither did I ever see an abscess situated at a distance from the original injury. I take it that the latter is to be explained by the early date of the suppuration, and the fact that in the great majority of small-calibre wounds the exit opening exists in the situation of the contre-coup damages of civil practice. The main feature in the symptoms when abscesses developed was the insidious mode of their appearance, usually at the end of fourteen to twenty-one days, and their comparative mildness. Very slight evidences of compression were observed; thus, varying degrees of headache, drowsiness, irritability of temper or depression, twitchings, or in some cases Jacksonian seizures, combined with slow pulse and slight rises of temperature. I never happened to see complete unconsciousness. The slight evidence of compression was perhaps explained in most cases by the large bony defect in the skull, which acted as a kind of safety-valve. Again the firm nature of the cicatricial tissue which formed at the periphery of the injury and extended up to the skull and there formed a more or less firm attachment, also preserved the actual brain tissue to some degree from either pressure or direct irritation. After evacuation of the pus, the usual difficulty was experienced in ensuring free drainage, and definitive healing and closure of the cavities was very slow. The following two cases will illustrate the character of the cases of cerebral abscess we met with:-- (70) _Fronto-parietal abscess._--Wounded at Magersfontein (Mauser). _Entry_, 1-3/4 inch above the line from the lower margin of the orbit to the external auditory meatus, and 1-3/4 inch behind the external angular process; _exit_, a little posterior to the left parietal eminence. There was right hemiplegia. The wounds were explored, and a large number of fragments of bone and pulped brain were removed, especially from the anterior wound. No great improvement followed, and the patient was sent to the Base. At this time there was a large hernia cerebri at the anterior wound which was suppurating. A further operation was here performed (Mr. J. J. Day). The hernia cerebri was removed, also several fragments of bone which were found deeply imbedded in the brain. The patient then improved, but a month later his temperature rose, and on exploration an abscess was discovered in the frontal lobe and drained. Subsequently the patient suffered with Jacksonian seizures, sometimes starting spontaneously, sometimes following interference with the wound. The convulsions commenced in the muscles of the face, and the twitchings then became general. Meanwhile the right upper extremity remained weak, although the fist could be clenched, and all movements of the limb made in some degree. Some difficulty was experienced in maintaining a free exit for the pus, which was however overcome by the use of a silver tube. All twitchings ceased about a month after the opening of the abscess, the man improved steadily, and he left for England fifteen weeks after the reception of the injury, walking well, with a firm hand-grip, and the wounds soundly healed. (71) _Frontal injury. Secondary abscess._--Wounded at Modder River. Aperture of _entry_ (Mauser), just external to the centre of the right eyebrow; _exit_, above the centre of the right zygoma. The wound did not render the man immediately unconscious, but he lost all recollection of what had happened to him for the next three or four days. The wounds were explored on the second day, at which time the patient was in a semi-conscious drowsy state, the pupils contracted and the pulse slow. A number of fragments of bone and pulped brain matter were removed. Subsequently to the operation the patient showed more signs of cerebral irritation than usual, lying in a semi-conscious state and more or less curled up. He answered questions on being bothered. He improved somewhat, and was sent to the Base, where the improvement continued, but he suffered much from headache. Later the headache became much more severe, and eleven weeks after the injury the man complained of great pain both locally and over the whole right hemisphere; he lay moaning, with the temperature subnormal, and the pulse very slow. At times there was nocturnal delirium. The wound had remained closed and apparently normal, but now a small fluctuating pulsating nipple-like swelling developed in the situation of the aperture of entry. This was incised, and two ounces of sweet pus evacuated (Professor Dunlop). A tube was introduced, and removed later on the cessation of discharge. Removal of the tube was followed by a recurrence of the same symptoms, and this occurred on no fewer than six occasions whenever the wound closed. At the end of twenty weeks the patient appeared quite well, the wound had been closed six weeks, the previously irritable mental state was replaced by placidity, and he was sent home. _Diagnosis._--The importance of proper exploration of scalp wounds to determine the condition of the bone has already been insisted upon. The localisation of the position and extent of the injury to the cranial contents depended simply on attention to the symptoms, and needs no further mention here. _Prognosis._--This subject can only be very imperfectly considered at the present time, since only the more or less immediate results of the injuries are known to us, while the more important after consequences remain to be followed up. As to life the immediate prognosis has been already foreshadowed in the section on the anatomical lesions. It is there shown that the first point of general importance is the range of fire at which the injury has been received. At short ranges, as evidenced by the history, the characters of the wounds, and the severity of the symptoms, the immediate prognosis was uniformly bad, a very great majority of the patients dying, and that at the end of a few hours or days. The rapidity with which death followed depended in part on the actual severity of the wound, and still more on the region it affected; the nearer the base and the longer the track the more rapidly the patients died, and this always with signs of failure of the functions of the heart and lungs due to general concussion, pressure from basal hæmorrhage, or rapid intracranial oedema. In my experience no patients survived direct fracture of the base in any region but the frontal, although many, no doubt, got well in whom fissures merely spread into the middle or posterior fossa. Patients with very extensive injuries at a higher level, on the other hand, often survived days, or even a week, then usually dying of sepsis. The actual relative mortality of these injuries I can give little idea of, but it was a high one both on the field and in the Field hospitals; thus of 10 cases treated in one Field hospital, after the battle at Paardeberg Drift, no less than 8 died; while of 61 cases from various battles who survived to be sent down to the Base during a period of some months, only 4 or 6.55 per cent. died. Many of the latter, as is seen from the cases here recorded which were among the number, were none the less of a very serious nature. The early causes of death in patients dying during the first forty-eight hours have been already mentioned; the later one was almost always sepsis. As in civil practice the best immediate results were seen in injuries to the frontal lobes, and after these in injuries to the occipital region. In the latter permanent lesions of vision were, however, common. The above injuries apart, the prognosis depended on the severity and depth of the lesion. The frequency and extent of radiation symptoms often made it possible to give a more hopeful prognosis than the immediate conditions seemed to warrant, if the exact situation of the lesion, and the probable velocity at which the bullet was travelling, were taken into account; since the actual destructive lesion, when the velocity had been insufficient to cause damage of a general nature, was often very strictly localised. Another very important point in the immediate prognosis was the primary union of the scalp wound; if this could only be ensured, few cases went wrong afterwards. Such remote effects as I witnessed were mainly the results of the actual destructive lesion, such as paralyses and contraction. I know of only one case in which early maniacal symptoms closely followed on a frontal injury, and here the symptoms accompanied the development of an abscess. Some patients were depressed and irritable, and some were blind or deaf, probably from gross lesion; in one patient the mental faculties generally were lowered. In spite of the surprising immediate recoveries which occurred, and the small amount of experience I am able to record as to remote ill effects of these injuries, I feel certain that a long roll of secondary troubles from the contraction of cicatricial tissue, irritation from distant remaining bone fragments, as well as mental troubles from actual brain destruction, await record in the near future. Since my return to England I have heard of four cases of injury to the head, which died on their return, as the result of the formation of secondary residual abscesses; and of one who died suddenly, soon after his return to active service in South Africa apparently well. These occurrences are sufficiently suggestive. It may be of interest to add here two cases of secondary traumatic epilepsy of differing degree:-- (72) _Gutter fracture over left temporo-sphenoidal lobe. Traumatic epilepsy._--A trooper in Brabant's Horse was wounded at Aliwal North, in March, in several places. A Mauser bullet entered the head 1-1/2 inch above the junction of the anterior border of the left pinna with the side of the head. The exit wound was situated just below and behind the left parietal eminence. The patient stated that the shot was fired by a man he recognised in a laager 150 yards distant from him. The man remained unconscious eleven days, and when he came round paralysis of the right upper extremity, and weakness of both lower extremities, were noted. There was also ataxic aphasia. The wounds healed, but two months later the man began to suffer from fits every few days. He spoke of them as fainting fits, but they were accompanied by general twitchings. The patient was shown to me in July by Major Woodhouse, R.A.M.C. The strength of the right upper extremity was then good, and he walked well. Speech was slow, but correct. The pupils were equal, and acted normally. The mental condition was weak, and the temper irritable. The man had hallucinations, and was very obstinate: there was complete deafness of the left ear. He refused surgical treatment, but was really hardly a responsible individual. (73) _Gutter fracture in right frontal region. Traumatic epilepsy._--Wounded at Pieter's Hill. Gutter fracture crossing the outer aspect of the frontal lobe, immediately above the level of the right Sylvian fissure. The wound was perforating at the central part, but only reached as far back as the lower end of the ascending frontal convolution. The patient was rendered unconscious and was removed to Mooi River. He was there seen by Sir William MacCormac, who removed a number of fragments of bone. The patient rapidly recovered consciousness after the operation, but was completely hemiplegic. After a month he suddenly found he was able to move his lower extremity, and later the paralysis became steadily less. On his return home the man obtained employment as a Commissionaire, but nine months after the injury, while his wife was helping him on with his coat one morning, he was suddenly seized with a fit; the paralysed arm was jerked up, and convulsions became general, a wedge needing to be inserted to prevent the tongue suffering injury. When admitted into the hospital, the cicatrix of the wound was considerably depressed, and the central part was evidently continuously attached to the surface of the brain. Pulsation was both visible and palpable, there was little or no tenderness on examination, and the patient did not complain of pain. Little trace of the left facial paralysis remained. The man walked well, but with foot-drop. The left upper extremity was rigid, but chiefly from the elbow downwards. The fingers were flexed, but a slight increase of grip could be effected. No other active movements of hand. The elbow was held flexed, but could be straightened to about 3/4 range on effort. The shoulder could be slightly abducted, but wide movements were made by the scapular muscles. Sensation was dull over the left side of the face, also over the left side of the neck. There was complete loss of cutaneous sensibility over the lower half of the forearm and hand, and a similar patch in the left axilla. Over the rest of the extremity the sensation was better on the flexor than on the extensor aspects. There was little alteration in the common sensation elsewhere, except that the contrast between that of the dorsum and sole of the foot was somewhat more marked than usual. The temperature of the insensitive axilla was one degree higher than that of the right. The left knee jerk was somewhat exaggerated. On December 15 an incision was made through the old cicatrix directly over the defect in the skull. On separating the skin it was found directly adherent to the cicatrised dura, and when this was incised a large vicarious arachnoid space was opened up. The space was crossed by a number of strands of connective tissue, and the cavity had no epithelial lining. The fluid ran out freely, and the space was evidently in free communication with the general arachnoid cavity. A trephine crown was taken out at the posterior end of the gutter, and the surface of the brain explored, but no fragments of bone were found. I therefore replaced the crown, and closed the bony defect in the floor of the gutter with a plate of platinum fitted into a groove made in the bony margin. The wound was then sutured. Primary union took place, and there was no constitutional disturbance beyond one temperature of 100° on the evening of the second day; otherwise the temperature remained normal, and the pulse did not rise above 75. On the second evening a fit occurred, coming on while the patient was apparently asleep. It lasted about a quarter of an hour and was general, the patient becoming for a short time unconscious, and passing water involuntarily. On the third morning two similar fits occurred, the first a severe one, during which the patient passed a motion involuntarily. The commencement of all three fits was observed by the nurse only, but in each the convulsions apparently commenced in the face and then became general. Three months later no further fits had occurred, and the patient, who throughout had said he felt remarkably well, complained of nothing. The upper extremity was apparently slightly less rigid than before the exploration, and the patient said he walked somewhat better than before. The closure of the skull was perfect. _Treatment._--The treatment of fractures of the skull possesses a degree of surgical interest that attaches to no other class of gunshot injury, since operative interference is necessary in every case in which recovery is judged possible. The injuries are, without exception, of the nature of punctured wounds of the skull, and the ordinary rule of surgery should under no circumstances be deviated from. An expectant attitude, although it often appears immediately satisfactory, exposes the patient to future risks which are incalculable, but none the less serious. Happily the operations needed may be included amongst the most simple as well as the most successful, and expose the patient with ordinary precautions to no increase of risk beyond that dependent on the original injury. Cases of a general character, or in which the base has been directly fractured other than in the frontal region, are seldom suitable for operation, since surgical skill is in these of no avail; but in all others an exploration is indicated. I use the word 'exploration' advisedly, since what may be called the formal operation of trephining is seldom necessary except in the case of the small openings due to wounds received from a very long range of fire; in all others there is no difficulty, but very great advantage, in making such enlargement of the bone opening as is necessary with Hoffman's forceps. The scalp should be first shaved and cleansed; if for any reason an operation is impossible, this procedure at least should be carried out, with a view to ensuring, as far as possible, future asepsis, infection in head injuries being almost the only danger to be feared. The shaving may need to be complete, but local clearance of the hair suffices in many cases. The hair having been removed, the scalp is cleansed with all care, a flap is raised of which the bullet opening forms the central point, and the wound explored. In slight cases the entry opening is the one of chief importance, and the exit may be simply cleansed and dressed. In some instances, as in direct fracture of the roof of the orbit from above, the exit should not be touched. The flap having been raised, if the wound be a small perforation, a 1/2-inch trephine crown may be taken from one side; but it is rare for the opening to be so small that the tip of a pair of Hoffman's forceps cannot be inserted. The trephine is more often useful in cases of non-penetrating gutter fractures where space is needed for exploration, and the elevation or removal of fragments of the inner-table. Loose fragments may need to be removed from beneath the scalp, but the important ones are those within the cranium. These may either be of some size, or fine comminuted splinters of either table, often at as great a distance as 2 inches or more from the surface. The cavity must be thoroughly explored and all splinters removed. I have seen more than fifty extracted in one case of open gutter fracture. The brain pulp and clot should then be gently removed or washed away, and the wound closed without drainage. Fragments of bone, as a rule, are better not replaced, but complete suture of the skin flap is always advisable in view of the great importance of primary union, and the fact that a drainage opening exists at the original wound of entry, and that the wound is readily re-opened to its whole extent, should such a step be advisable. The detection of fragments is easiest and most satisfactorily done with the finger, and in all but simple punctures the opening should be large enough to allow thoroughly effective digital exploration; the remarks already made as to the factors determining the size of fragments are of interest in this connection. The determination of the amount of brain pulp which should be removed is somewhat more difficult; one can only say that all that washes readily away should be removed, and its place is usually taken up by blood. Few fractures of the base are suitable for treatment; the only ones I saw were those of direct fracture of the roof of the orbit or nose, produced by bullets passing across the orbits; here the advisability of interference with the injured eye led to opening of the orbit, and sometimes exposed the fracture. Some patients recovered, even when the damage had been sufficient to cause escape of pulped brain into the orbit. The after treatment simply consisted in keeping the patients as quiet as circumstances would permit, and the administration of a fluid diet. In some cases recurring symptoms pointed to the continued presence of bone fragments; these were usually indicated by signs of irritation, or often of local inflammation, in the latter case infection taking the greater share in the causation. Such cases needed secondary exploration, and the wonderful success of this operation, even when the wound was evidently infected, was perhaps one of the most striking experiences of the surgery in general. I should add a word here as to the most satisfactory time for the performance of these operations; as in all cases the earlier they could be undertaken the better, but in the head injuries the advantages of early interference were more evident than in any other region. This depended on the fact that, as in civil practice, the scalp is one of the most dangerous regions as far as auto-infection of the wound is concerned, and one of the most difficult to cleanse, except by thorough shaving. Beyond this the extreme simplicity of the operative procedure needed, called for few precautions beyond those for asepsis, and very little armament in the way of instruments, &c. When on the march from Winberg to Heilbron with the Highland Brigade we had some five days' continuous fighting, and on this occasion several perforating fractures of the skull were brought in. The coldness of the nights at that time made evening operations an impossibility; hence the operations on these men were performed at the first dressing station, in the open air, at the side of the ambulance wagons, often during the progress of fighting around. Of several cases so operated on, all healed by primary union without a bad symptom of any kind, except one (see p. 249), in whom a very large entrance opening over the right cortical motor area led down to an extensive destruction of the brain, complicated by a fracture of the base in the middle fossa. This wound, from the first considered hopeless, became septic during the four days' travelling in an ambulance wagon that was necessary, and the man died at the end of fourteen days. As the whole cortical motor area was destroyed, death was, perhaps, the end most to be desired; but the fight that this man made for recovery, and the fact that his death, after all, was due to general infection and not to any local extension of the injury, very strongly impressed me with the possibility of recovery, even in such extensive cases, if only an aseptic condition can be maintained. I saw many other cases of the same nature, particularly in men who, as a result of unfortunate circumstances, were necessarily left out on the field for more than twenty-four hours. In some of these maggots were found in the wounds only thirty-six hours after the infliction of the injury. I have said nothing as to the treatment of the large primary herniæ cerebri in wounds of an explosive nature, since these were rarely subjects suitable for operation; but in the instances of minor severity they were treated as the other cases where the pulped brain lay mostly within the skull. In cases where the wounds were in the frontal or fronto-parietal regions, and hemiplegia existed, the rapid improvement in the paralytic symptoms, after operation, was very marked, showing that the signs were mainly, or entirely, due to 'radiation' injury. I am inclined to think that temporary injury of this kind from vibratory disturbance and small parenchymatous hæmorrhages, were far more often the cause of the paralysis than surface hæmorrhage, since the latter was rarely found in large quantity. Large clots, however, no doubt growing in both size and firmness, occasionally occupied the area of destroyed brain, and these sometimes manifestly exercised pressure that was at once relieved by their evacuation. In cases where inflammatory hernia cerebri developed, a secondary exploration was often indicated for the removal of fragments of bone or the evacuation of pus, otherwise the condition was best treated by dry dressings and gentle support. Abscess of the brain was treated by simple evacuation and drainage by metal or rubber tubes: the operations were always of extreme simplicity, since the abscess in every case I saw was in the direct line of the wound track, and was readily opened by the insertion of a director or blunt knife. The only trouble in the after treatment was that already referred to, of preventing premature closure of the drainage opening. I have made no special reference to the method of dressing, since it was of the ordinary routine kind. The most important factor in success was the efficient primary disinfection of the scalp; a piece of antiseptic gauze and some absorbent wool, efficiently secured, was all that was needed later. As usual the consideration of the treatment of cases in which the bullet was retained may be considered last. Such accidents were distinctly rare. I operated in only one (No. 54, p. 260) in whom the indications both for localisation and interference were obvious, since the bullet had palpably fractured the bone, although it had not retained sufficient force to enable it to leave the skull. In two other cases that I saw, in one the bullet was lodged in the zygomatic fossa, in the second just below the mastoid process. The former patient died; the latter exhibited symptoms indicative of injury to the occipital lobe (No. 68), and was successfully treated by Mr. J. E. Ker. I never happened to see a case in which a retained bullet in the skull was localised by the X rays, but such might have been possible in case No. 64, p. 275. In no case is primary interference indicated, unless a fracture exists where the bullet has tried to escape, or secondary symptoms develop pointing to irritation. Under ordinary circumstances, moreover, the indications for removal of a bullet are not likely to be sufficiently imperative to necessitate the operation being undertaken until the patient can be placed under the best conditions that can be secured. This is the more advisable since such operations need the infliction of an additional wound, require great delicacy, and may be very prolonged in performance. The experience of civil practice has already sufficiently proved the small amount of inconvenience likely to follow the retention of a bullet in the skull. I may again mention the fact that in explorations for the removal of bone fragments, fragments of lead, from breaking or setting up of the bullet, are sometimes found. Taken as a whole, the operations on the head were extremely satisfactory from a technical point of view; the large depressed pulsating cicatrix so often left was the chief defect observed. The circumstances under which many of the operations had to be performed militated strongly, however, against the successful replacement of separated bone fragments, which might have rendered the defects less serious. Secondary operations for traumatic epilepsy scarcely come within the scope of these experiences. In case 73, p. 292, it is of interest to note the manner in which the cavity due to loss of brain substance was filled up. No doubt a similar vicarious arachnoid space develops in all cases in which a soft pulsating swelling fills an aperture in the bones of the skull. WOUNDS OF THE HEAD NOT INVOLVING THE BRAIN _Mastoid process._--The most important wound of the cranium not already mentioned was that involving the mastoid process and the bony capsule of the ear. Wounds of the mastoid process obtained their chief interest in connection with paralysis of the seventh nerve. This nerve rarely or never escaped, and, as far as my experience went, the facial paralysis was permanent (see cases 111-114, p. 355). I think the same prognosis holds good with regard to the deafness resulting from these injuries, and it is difficult to believe, with our experience of the effect of vibration on other nerve centres and organs, that the internal ear could ever escape permanent damage. In a number of cases the tympanum itself, or the external auditory meatus, was directly implicated in tracks; in these, also, loss of hearing was the rule. Wounds of the pinna when produced by undeformed bullets were usually of the same slitlike nature remarked in perforations of the cartilages of the nose, and healed with equal rapidity. _Wounds of the orbit._--Injuries to the orbit were very numerous and serious in their results, both to the globe of the eye and the surrounding structures. _Anatomical lesions._--The wound tracks, with regard to the injuries produced, may be well classified according to the direction they took; thus--vertical, transverse, and oblique. Vertical wound tracks were on the whole the least serious, but this mainly from the fact of limitation of the injury to one orbital cavity. They were usually produced by bullets passing from above downwards through the frontal region of the cranium, and were received by the patients while in the prone position. Transverse and oblique wounds owed their greater importance to the fact that both eyes were more likely to be implicated. Besides these tracks, which actually crossed the cavities, a number involved the bony boundaries, producing almost as severe lesions in the globe of the eye, many of the patients being rendered permanently blind. The only difference in nature of such cases was the escape of orbital structures, and this was of minor importance in the presence of the graver lesion to vision. The following is an illustrative case:-- (74) Wounded at Colenso. _Entry_ (Mauser), 1 inch below the centre of the margin of the right orbit; _exit_, behind the right angle of the mandible. Fracture of lower jaw, and development of a diffuse traumatic aneurism of the external carotid artery. The common carotid artery was tied for secondary hæmorrhage (Mr. Jameson) some three weeks later. Vision was affected at the time of the accident; the fingers could be seen, but not counted. After ligation of the carotid the condition was possibly worse, and this needs mention as transitory loss of power in the left upper extremity also followed the operation. Fractures of the bony wall were of every degree. The most severe that I saw were two in which lateral impact by a bullet crossing the cranial cavity caused general comminution of the whole orbital roof. Fissures of the roof were common in connection with 'explosive' exit apertures in the frontal region of the skull. Pure perforations usually accompanied the vertical or transverse wounds of the cavity, fragments at the aperture of entry then being projected into the orbit, sometimes penetrating the muscles. Occasionally the margin of the cavity was merely notched. The ocular muscles were often divided more or less completely, and occasionally some difficulty arose in determining whether loss of movement of the globe in any definite direction depended on injury to the muscle itself, or to the nerve supplying the muscle. The following case illustrates this point:-- (75) _Entry_ (Mauser), 2 inches behind the right external canthus; the bullet pierced the external wall and traversed the floor of the right orbit beneath the globe, crossed the nasal cavity, and a part of the left orbit; _exit_, at the lower margin of the left orbit, beneath the centre of the globe of the eye. Complete loss of sight followed the injury, and persisted for one week. Modified vision then returned. Three weeks later there was diplopia; loss of function of the right external and inferior recti, although the ball could be turned downward to some extent by the superior oblique when the internal rectus was in action. Movements of the left globe were not seriously affected. The pupils were immobile and moderately dilated, but atropine had been employed two days previously. A year later the condition was as follows: There is some weakness of the right seventh nerve, as evidenced by want of symmetry in all the folds of the face, and in narrowing of the palpebral fissure. When at rest the right eye is somewhat raised and turned outwards. Active movements outwards or downwards are restricted. There is diplopia, and the vision of the right eye is much impaired; the man can see persons, but cannot count fingers with certainty, although he sees the hand. Putting on one side the loss of free movement, there is no obvious external appearance of injury to the eye. Mr. J. H. Fisher reported as follows: Ophthalmoscopic examination shows the left eye and fundus to be normal. The right disc is not atrophied, but the whole of the lower half of the fundus is coated with masses of black retinal pigment. There is atrophy in spots of the capillary layer of the choroid, and the larger vessels of the deeper layer are exposed between the interstices of the pigment masses. There is no definite choroidal rupture. The lesion encroaches upon and implicates the macular region. The injury is a concussion one, not necessarily resulting from contact, and certainly not due to a perforation. The loss of movement and faulty position are the result of injury to the muscles, and not to nerve implication. The man complained that when he blew his nose the left eye filled with water and air came out. The left nasal duct was however shown to be intact, as water injected by the canaliculus passed freely into the nose. Intra-orbital bleeding, subconjunctival hæmorrhage with proptosis and ecchymosis of the lids were usually well marked. The latter was sometimes extreme. Injury to the nerves was naturally of a very mixed character. In many instances the branches of the first two divisions of the fifth nerve were obviously implicated and regional anæsthesia was common. This was often transitory when the result of vibratory concussion, contusion, or pressure from hæmorrhage. In other cases it was more prolonged as a result of actual division of the nerve. As is usually the case, when a small area of distribution only was affected, sensation was rapidly regained from vicarious sources, even when section had been complete. As individual injuries, those to the optic nerve were the most frequently diagnosed. I am sorry to be unable to attempt a discrimination of injuries to the nerve alone from those in which both nerve and globe suffered, but the globe can rarely have escaped injury, either direct or indirect, when the bullet actually traversed the orbital cavity. (A few further remarks concerning injuries to the optic nerve will be found in Chapter IX.) Injuries to the globe of the eye, either direct or indirect, accompanied most of the orbital wounds. In some the lesion was of the nature of concussion. In such the bone injury was usually at the periphery of the orbit, or to the bones of the face in the neighbourhood. The loss of vision might then be temporary, persisting from two to ten days, then returning, often with some deficiencies. In other similar external injuries, the lesion of the globe was more severe, and permanent blindness followed. In variability of degree of completeness, these lesions of the globe corresponded exactly with those produced in other parts of the nervous system by bullets striking the bones in their vicinity, and they were no doubt the result of a similar transmission of vibratory force. In a third series of cases the globe suffered direct contusion, and in a fourth was perforated and destroyed. In cases in which permanent blindness was produced without solution of continuity of the sclerotic coat, the nature of the lesion was probably in most cases vibratory concussion and the development of multiple hæmorrhages from choroidal ruptures of a similar nature to those seen in the brain and spinal cord. The actual hæmorrhagic areæ varied in size; but, as far as my experience went, gross hæmorrhages into the anterior chamber did not occur without severe direct contact of the bullet. In the vast majority of the cases blindness, whether transitory or permanent, developed immediately on the reception of the injury, and was possibly in its initial stage the result of primary concussion. Cases were, however, seen occasionally in which the symptoms were less sudden, of which the following is an example. I did not think that the mode of progress seen here could be referred to simple orbital hæmorrhage, although this existed, but rather to intravaginal hæmorrhage into the sheath of the optic nerve. On external inspection the globes appeared normal. (76) Wounded at Paardeberg. _Entry_ (Mauser), over the centre of the right zygoma; the bullet traversed the right orbit, nose, and left orbit. _Exit_, immediately above the outer extremity of the left eyebrow. The patient stated that he could 'see' for thirty minutes with the right eye and for an hour with the left, immediately after the injury. He then became totally blind, and has since remained so. During the next three weeks there were occasional 'flashes of light' experienced, but these then ceased. At the end of three weeks the condition was as follows: Ocular movements good in every direction except that of elevation of the globe. The levator palpebræ superioris acted very slightly; the right, however, better than the left. There were marked right proptosis, less left proptosis, and slight patchy subconjunctival hæmorrhage of both eyes. The pupils were dilated, motionless, and not concentric. The patient was invalided as totally blind (November, 1900). Mr. Lang, who saw this patient on his return to England, kindly furnishes me with the following note as to the condition. There was extensive damage to both eyes, hæmorrhage, and probably retinal detachment as well as choroidal changes. The quotation of a few illustrative examples typical of the ordinary orbital injuries may be of interest:-- (77) _Vertical wound._--_Entry_, into left orbit in roof posterior to globe, and internal to optic nerve; _exit_, from orbit through junction of inner wall and floor into nose. Complete blindness followed the injury, but upon the second day light was perceived on lifting the upper lid. There was marked proptosis, subconjunctival ecchymosis, swelling and ecchymosis of the upper lid, and ptosis. Anæsthesia in the whole area of distribution of the frontal nerve. At the end of three weeks, fingers could be recognised, but a large blind spot existed in the centre of the field of vision. The general movements of the globe were fair, but the upper lid could not be raised. The proptosis and subconjunctival hæmorrhage cleared up. Little further improvement occurred; six months later the patient could only count the fingers excentrically. A very extensive scotoma was present. The optic disc was much atrophied, the calibre of the arteries diminished and the veins full (Mr. Critchett). The ptosis persisted. It was doubtful in this case whether the ptosis depended on injury to the nerve of supply, or on laceration and fixation of the levator palpebræ superioris. The latter seemed the more probable, as the superior rectus acted. The absence of any sign of gross bleeding into the anterior chamber is opposed to the existence of a perforating lesion of the globe in this case. (78) _Entry_ (Mauser), from cranial cavity, just within the centre of the roof of the right orbit; _exit_, from the orbit by a notch in the lower orbital margin internal to the infra-orbital foramen; track thence beneath the soft parts of the face to emerge from the margin of the upper lip near the left angle of the mouth. Collapse of globe, proptosis, subconjunctival hæmorrhage, oedema and ecchymosis of lids. Shrunken ball removed on twenty-fourth day (Major Burton, R.A.M.C.). (79) _Entry_ (Mauser), at the posterior border of the left mastoid process, 3/4 inch above the tip; _exit_, in the inner third of the left upper eyelid. Globe excised at end of seven days. Facial paralysis and deafness. (80) _Entry_ (Mauser), from cranial cavity through centre of roof of orbit; _exit_, through maxillary antrum. Total blindness. Movements of ball good, no loss of tension. Proptosis, subconjunctival hæmorrhage, ecchymosis of eyelids. No improvement in sight followed. One month later the globe suppurated and was removed. The bullet had divided the optic nerve and contused the ball. _Prognosis and treatment of wounds of the orbit._--Except in those cases in which return of vision was rapid, the prognosis was consistently bad in the injuries to the globe. When the globe was ruptured it, as a rule, rapidly shrank. The case (80) quoted above is the only one in which I saw secondary suppuration. With regard to active treatment, the majority of the cases were complicated by fracture of the roof of the orbit, and in many instances concurrent brain injury was present. In all of these, as a general rule, it was advisable to await the closure of the wound in the orbital roof prior to removal of the injured eye, if that was considered necessary. The only exception to this rule was offered by instances in which the bullet passed from the orbit into the cranium; in these primary removal of fragments projecting into the frontal lobe was preferable. As already indicated, such wounds were comparatively rare except in the case of bullets coursing transversely or obliquely. The wounds were, as a rule, followed by considerable matting of the orbital structures. _Wounds of the nose._--I will pass by the external parts, with the remark that perforating wounds of the cartilages were remarkable for their sharp limitation and simple nature. I remember one case shown to me in the Irish Hospital in Bloemfontein by Sir W. Thomson, in which at the end of the third day small symmetrical vertical slits in each ala already healed were scarcely visible. This case very strongly impressed one with the doctrine of chances, since on the same morning I was asked to see a patient in whom a similar transverse shot had crossed both orbits, destroying both globes and injuring the brain. A retained bullet in the upper portion of the nasal cavity has already been referred to (fig. 60). This accident was naturally a rare one; in that instance the bullet had only retained sufficient force to insert itself neatly between the bones. Wounds crossing the nasal fossæ were comparatively common. The interference with the sense of smell often resulting is discussed in Chapter IX. _Wounds of the malar bone_ were not infrequent. The small amount of splintering was somewhat remarkable considering the density of structure of the bone. In this particular the behaviour of the malar corresponded with what was observed in the flat bones in general. A case quoted in Chapter III. p. 87, illustrates the capacity of the hard edge of the bone to check the course of a bullet, and cause considerable deformity and fissuring of the mantle. _Wounds of the jaws. Upper jaw._--A large number of tracks crossing the antrum transversely, obliquely, or vertically were observed. In the first case the nasal cavity, in the others the orbital or buccal cavity, were generally concurrently involved. It was somewhat striking that I never observed any trouble, immediate or remote, from these perforations of the antrum. If hæmorrhage into the cavity occurred, it gave rise to no ultimate trouble. I never saw an instance of secondary suppuration even in cases where the bullet entered or escaped through the alveolar process with considerable local comminution. The branches of the second division of the fifth nerve were sometimes implicated. In one instance a bullet traversed and cut away a longitudinal groove in the bones, extending from the posterior margin of the hard palate, and terminating by a wide notch in the alveolar process. A good example of a troublesome transverse wound of the bones of the face is afforded by the following instance:-- (81) _Entry_ (Mauser), through the left malar eminence, 1 inch below and external to the external canthus; _exit_, a slightly curved tranverse slit in the lobe of the right ear. The injury was followed by no signs of orbital concussion, and no loss of consciousness. There was free bleeding from both external wounds and from the nose. The sense of smell was unaffected, but taste was impaired, and there was loss of tactile sensation in the teeth on the left side also on the hard palate. There was no evidence of fracture of the neck of the mandible, nor of the external auditory meatus, but there was considerable difficulty in opening the mouth widely or protruding the teeth. The latter difficulty persisted for some time, and was still present when I last saw the patient. _Mandible._--Fractures of the lower jaw were frequent and offered some peculiarities, the chief of which were the liability of any part of the bone to be damaged, and the absence of the obliquity between the cleft in the outer and inner tables so common in the fractures seen in civil practice. The neck of the condyle I three times saw fractured; in each instance permanent stiffness and inability to open the mouth resulted. This stiffness was of a degree sufficient to raise the question whether the best course in such cases would not be to cut down primarily and remove a considerable number of loose fragments, and thus diminish the amount of callus likely to be thrown out. Fractures of the ascending ramus and body were more frequent. They were accompanied by considerable comminution, but all that I observed healed remarkably well, and in good position, in spite of the fact that many of the patients objected to wear any form of splint. The most special feature was the occurrence of notched fractures, corresponding to the type wedges described in Chapter V. When these fractures were at the lower margin of the bone, the buccal cavity occasionally escaped in spite of considerable comminution, the latter confining itself to the basal portion of the bone. When the base of the teeth, or the alveolus, was struck, a wedge was often broken away, and from the apex of the resulting gap a fracture extended to the lower margin of the bone. When fractures of the latter nature resulted from vertically coursing bullets, much trouble often ensued. I will quote two cases in illustration:-- (82) Wounded at Rooipoort. _Entry_ (Mauser), through the lower lip; the bullet struck the base of the right lateral incisor and canine teeth, knocked out a wedge, and becoming slightly deflected, cut a vertical groove to the base of the mandible; _exit_, in left submaxillary triangle. The bullet subsequently re-entered the chest wall just below the clavicle, and escaped at the anterior axillary fold. The appearance of these second wounds suggested only slight setting up of the bullet; the original impact was no doubt of an oblique or lateral character. The injury was followed by free hæmorrhage and remarkably abundant salivation (I was inclined to think that the latter symptom was particularly well marked in gunshot fractures of the body of the mandible), and very great swelling of the floor of the mouth. The patient could not bear any form of apparatus, but was assiduous in washing out his mouth, and made a good recovery, the fragments being in good apposition. (83) _Entry_ (Mauser), over the right malar eminence; the bullet carried away all the right upper and lower molars, fractured the mandible, and was retained in the neck. A fortnight later an abscess formed in the lower part of the neck, which was opened (Mr. Pooley), and portions of the mantle and leaden core, together with numerous fragments of the teeth, were removed. The bullet had undergone fragmentation on impact, probably on the last one (teeth of mandible), and still retained sufficient force to enter the neck. This case affords an interesting example of transmission of force from the bullet to the teeth, and bears on the theory of explosive action. In the treatment of fractures of the upper jaw, interference was rarely needed. In the case of the mandible, a remark has already been made as to the advisability of removing fragments when the neck of the condyle has suffered comminution. The removal of loose fragments is necessary in all cases in which the buccal cavity is involved. Experience in fracture of the limbs has shown a tendency to quiet necrosis when comminution was severe, in spite of primary union. This is no doubt dependent on the very free separation of fragments on the entry and exit aspects from their enveloping periosteum. In the case of the mandible, considerable necrosis is inevitable, and much time is saved by the primary removal of all actually loose fragments. A splint of the ordinary chin-cap type with a four-tailed bandage meets all further requirements, but the patients often object to them. Cases in which the fragments could be fixed by wiring the teeth were not common, as the latter had so frequently been carried away. The usual precautions as to maintaining oral asepsis were especially necessary. The results of fractures of the mandible were, in so far as my experience went, remarkably good, as deformity was seldom considerable. The absence of obliquity and the effect of primary local shock were no doubt favourable elements, little primary displacement from muscular action occurring. Wounds of the _cheek_ healed readily, and the same was noticeable of the lips. Wounds of the _tongue_ healed with remarkable rapidity when of the simple perforating type, often with little or no swelling or evidence of contusion. At the end of a few days it was often difficult to localise them. In connection with this subject a remarkable case which occurred at the fighting at Koodoosberg Drift is worthy of mention, although the projectile was a shell fragment and not a bullet of small calibre. (84) A Highlander was the unfortunate possessor of an entire set of upper teeth set in a gold plate. A small fragment of a shell perforated the upper lip by an irregular aperture, and struck the teeth in such a manner as to turn the posterior edge of the plate towards the tongue, which latter was cut into two halves transversely through to the base. The patient asserted that the plate had been driven down his throat, but nothing was palpable either in the fauces or on external examination of the neck. He spoke distinctly, but there was dysphagia as far as solids were concerned. On the second day swelling of the neck due to early cellulitis developed, especially on the left side, and signs of laryngeal obstruction became prominent. Chloroform was administered, but on the introduction of the finger into the fauces, respiration failed and a hasty tracheotomy had to be performed. No foreign body was palpable with the finger in the pharynx. Tracheitis and septic pneumonia developed, and the man died of acute septicæmia thirty-six hours later. Death occurred just as the Division received marching orders, and no _post-mortem_ examination was made. As a result of palpation at the time of the tracheotomy, the probabilities seemed against the presence of the tooth plate in the pharynx, but the absence of positive evidence scarcely allows the case to be certainly classed as one of cellulitis and septicæmia secondary to wound of the tongue. WOUNDS OF THE NECK Wounds of the neck were not unfrequent and were of the gravest importance; there can be little doubt that they accounted for a considerable proportion of the deaths on the field. On the other hand, the neck as a region offered some of the most striking examples of hairbreadth escape of important structures. Consideration of a number of the vascular lesions (see cervical aneurisms, p. 135) also shows conclusively that in no region did the small size of the bullet more materially influence the result, since no doubt can exist that all these wounds would have proved immediately fatal if produced by projectiles of larger calibre. In this place only a few general considerations will be entered into, as most of the important cases are dealt with under the general headings of vessels, nerves, and spine; but it is convenient to include here the few remarks that have to be made concerning the cervical viscera. The wounds of the soft parts might course in any direction, but vertical tracks from above downwards were rare. In point of fact, these occurred only in connection with perforations of the head, and as vertical wounds of the latter were received in the prone position, usually when the head was raised, the necessary conditions for longitudinal tracks were seldom offered. One case of a complete vertical track in the muscles of the back of the neck has been already quoted (No. 69, p. 286). Tracks coursing upwards from the trunk were somewhat more frequent in occurrence; thus a considerable number traversing the thorax were seen. In such instances the aperture of exit was generally situated in the posterior triangle, and some of the brachial nerves often suffered. The commonest forms of wound were the transverse or the oblique. A large number of cases with such tracks will be found among the cases of injury to the cervical vessels and nerves. In some instances the course was restricted to the neck alone, in others the trunk or upper extremity was also implicated. The favourable influence of the arrangement of the structures of the neck, which allows of the ordinary displacement excursions necessary for deglutition, respiration, and their cognate movements, was very strongly marked. Thus in several cases the bullet traversed the neck behind the pharynx and oesophagus without injuring either viscus, and the escape of the main vessels and nerves was equally striking. In such wounds the wedge-like bullet without doubt separated and displaced all these structures, causing mere superficial contusion. In connection with the latter statement, the rarity of direct sagittal wounds in the hospitals should be mentioned. This is probably to be explained by the facts that wounds in the mid-line of the neck implicated the cervical spinal cord, and that sagittal wounds implicating the vessels were apt to lead more directly to the surface, and thus external hæmorrhage was favoured. A few examples of cervical tracks will suffice to illustrate these remarks:-- (85) _Entry_ (Lee-Metford), below angle of scapula; _exit_, centre of posterior triangle. Injury to the lung, and hæmothorax. No damage to neck structures. (86) _Entry_ (Mauser), over Pomum Adami; _exit_, below right scapular spine. Median and musculo-spiral paralysis. (87) _Entry_, a large oval aperture through ninth right rib, 1/2 an inch external to scapular angle; _exit_, anterior border of sterno-mastoid opposite Pomum Adami. Second entry, opposite angle of mandible; exit, in centre of cheek. Wound of lung. Musculo-spiral paralysis still persisting at the end of nine months. (88) _Entry_ (Mauser), 2 inches above left clavicle at margin of trapezius; _exit_, 1 inch from sternum in left first intercostal space. Contusion of brachial plexus, with mixed signs, which disappeared in two months. No signs of vascular injury. See also cases of cervical aneurism, &c. _Wounds of the pharynx._--I saw only three cases of wound of the pharynx; in each the injury was in the nasal or buccal segment of the cavity, and in each the soft palate was injured, in two instances the wound being a small perforation. All three cases belong to the somewhat miraculous class. The first (89) was the only one in which the wound gave rise to subsequent trouble. The second was under the charge of Mr. Bowlby, and will no doubt be more fully recounted by him, as interesting signs of injury to the cervical cord were present. In the third the occipital neuralgia was the only troublesome symptom. In both cases 90 and 91 the high position of the wound in the fixed portion of the pharynx no doubt accounted for the absence of any infective trouble. (89) _Wounds of the pharynx._--_Entry_ (Lee-Metford), immediately below the tip of right mastoid process; the bullet traversed the neck, entering the pharynx close to the right tonsil, crossed the cavity of the pharynx and the mouth, emerging through the left cheek. Great swelling of the fauces and dysphagia persisted for some days after the injury, and there was considerable hæmorrhage. Infection of the posterior portion of the track from the pharynx resulted, and suppuration continued for some weeks: a small sequestrum eventually needed to be removed from the tip of the transverse process of the atlas. (90) _Entry_ (Mauser), through mouth; the bullet pierced the soft palate and the posterior wall of the pharynx, and passed out between the transverse process of atlas and the occiput. No serious pharyngeal symptoms. (91) _Entry_ (Mauser), through the mouth, knocking out the left upper canine and bicuspid teeth. Perforation of the soft palate just to the right of the base of the uvula and the posterior wall of the pharynx; _exit_, 1-1/2 inch internal to and 1/2 an inch below the tip of the right mastoid process. Hæmorrhage persisted for half an hour, and the patient could not swallow solids for a week. Great occipital neuralgia followed the wound. _Wounds of the larynx._--I saw only one wound of the larynx (see No. 10, p. 135). In this instance the thyroid cartilage was wounded on either side at the level of the Pomum Adami. Transitory hæmorrhage and signs of oedema were the only signs referable to the wound, but in addition the bullet contused the left vagus and gave rise to temporary laryngeal paralysis. The same course was observed in a second case of perforation of the larynx of which I was told. _Wounds of the trachea._--The two cases recounted below are the only tracheal injuries I met with; in one the oesophagus was also implicated. This patient died from mediastinal emphysema. In the second case the wide development of emphysema was prevented by the early introduction of a tracheotomy tube. (92) _Entry_ (Mauser), on the outer side of the right arm, 3-1/2 inches below the acromion; _exit_, 3 inches below the tip of the left mastoid process, through the sterno-mastoid. Thirty six hours later there was very free hæmorrhage into the right posterior triangle, emphysema at the episternal notch, dysphagia, and complete obliteration of the cardiac area of dulness. Respiration was rapid (40) and extremely noisy. Pulse 130, small and weak. A tracheotomy was performed (Mr. Stewart), but the patient died an hour later. When the operation was performed a considerable amount of mucus from the oesophagus was discovered in the wound. The bullet had passed obliquely between trachea and oesophagus, wounding both tubes. (93) _Entry_, at the centre of the margin of the left trapezius; _exit_, in mid line of the neck over the trachea. Dyspnoea was noted the next morning, which increased during a journey in a wagon. On the third day the dyspnoea was more troublesome and emphysema began to develop in the neck. A tracheotomy was performed (Mr. Hunter), and the tube was kept in for four days. No further trouble was experienced, and the wound shortly closed, and the patient, a surgeon, returned to his duties. Temporary signs of median nerve concussion and contusion were noted. CHAPTER VIII INJURIES TO THE VERTEBRAL COLUMN AND SPINAL CORD Every degree of local injury to the constituent vertebræ and the contents of the spinal canal was met with considerable frequency. Pure uncomplicated fractures of the bones were of minor importance, except in so far as they exemplified the general tendency to localised injury in small-calibre bullet wounds. Injuries implicating the spinal medulla, on the other hand, were proportionately the most fatal of any in the whole body to the wounded who left the field of battle or Field hospital alive, and these cases formed one of the most painful and distressing features of the surgery of the campaign. The prognostic gravity of any spinal injury depended upon two factors: first, the obvious one of relative contiguity or direct implication of the cord or nerves in the wound track; secondly, the degree of velocity retained by the bullet at the moment of impact with the spine. Observation of the serious ill effects produced by bullets passing in the immediate proximity of large strongly ensheathed peripheral nerves surrounded by soft tissue, such as those of the arm or thigh, would lead one to expect that a comparatively thin-clad bundle of delicate nerve tissue like the spinal cord, enclosed in a bony canal so well disposed for the conveyance of vibrations, would suffer severely, and such proved to be the case. _Fractures in their relation to nerve injury_ will be first dealt with, and secondly injuries to the cord itself. Isolated fractures of the processes were not uncommon, the determination of the injury to anyone being naturally dependent on the position and direction taken by the wound track. For implication of the _transverse processes_ sagittal wounds coursing in varying degrees of obliquity were mainly responsible. Such injuries might be unaccompanied by any nerve lesion. Thus a Boer received a Lee-Metford wound at Belmont which passed from just below the tip of the right mastoid process across the pharynx and through the opposite cheek. No bone damage was at first suspected; suppuration in the neck, however, followed infection from the pharynx, and when a sinus which persisted was opened up later, a number of small comminuted fragments were found detached from the transverse process of the axis. In other cases more or less severe symptoms of nerve lesion were observed, varying from transient hyperæsthesia, due to implication of the issuing nerves, to symptoms of spinal hæmorrhage, such as are portrayed in the following:-- (94) A private in the Black Watch was wounded at Magersfontein from within a distance of 1,000 yards. Among other wounds, one track entered 1 inch to the right of the second lumbar spinous process, and emerged 1 inch internal to the right anterior superior iliac spine. There were signs of wound of the kidney, and in addition, retention of urine, incontinence of fæces, complete motor and sensory paralysis of the right lower extremity, and total absence of all reflexes. Anæsthesia existed over the whole area of skin supplied by the nerves of the sacral plexus, hyperæsthesia over that supplied by the lumbar nerves. On the tenth day subsequent to the injury, the hyperæsthesia in the area of lumbar supply was replaced by normal sensation, motor power began to be slowly regained in the muscles supplied by the anterior crural and obturator nerves, and the patellar reflex returned. At this time lowered sensation returned in the area supplied by the sacral plexus, but no improvement in motor power took place, and no control was regained over the bladder and rectum. During the succeeding week some sciatic hyperæsthesia developed, but on the twenty-eighth day the patient developed secondary peritonitis from other causes and died on the thirty-first. A fracture of the transverse process existed, but unfortunately the spinal canal was not opened for examination and no details can be given as to the condition of the cord. (See case 201, p. 463.) Fractures of the _spinous processes_, or those involving both the process and laminæ, were not uncommon. Isolated separation of the spinous process was usually the result of wounds crossing the back obliquely or transversely. Examples of this injury were numerous, especially in the dorsal region, as being the most prominent, particularly when the patients assumed the prone position when advancing on the enemy. Cervical injuries, owing to the comparatively sheltered position of the more deeply sunk spines, and from the fact that the head was usually under cover of a stone or ant-heap, were less common; in one instance hyperæsthesia was noted in one upper extremity as the result of a crossing bullet having struck the fourth cervical spine. In a man wounded at Paardeberg Drift the bullet entered at the centre of the buttock, traversed the bones of the pelvis, and, leaving that cavity above the crest of the ilium, crossed the spine to emerge in the opposite loin. Suppuration occurred, and when the wound was laid open the third and fourth lumbar spinous processes were found to be loosened, but still connected to the surrounding soft parts. There were no nerve symptoms in this case; these would not have been expected, since by the time that the bullet had traversed the bones of the pelvis its velocity must have been considerably lessened, even if high at the moment of primary impact. In another case a dorsal spine, together with its lamina, was separated and moveable; the only nerve symptoms were slight pain and a crop of herpes on the line of distribution of the corresponding intercostal nerve, the bullet having probably struck the nerve in passing across the intercostal space. In one instance of a retained bullet lying beneath the skin of the back, its passage between two contiguous dorsal spines without fracture of either was determined during an extraction operation. When the prone position was assumed by the men, more or less longitudinal wounds in the course of the spine were naturally liable to occur. These tracks assumed somewhat greater importance than the transverse ones, because the injury to bone was more often multiple, and the laminæ were frequently implicated. The relative importance of such injuries was dependent on the velocity of the bullet and the depth at which it travelled. As an instance of a more serious character the following may be given:-- (95) In a Highlander wounded at Magersfontein, probably at a range within 1,000 yards, the bullet entered at the right side of the sixth cervical vertebra; tracking downwards, it loosened the laminæ of the fifth and sixth dorsal vertebræ from the pedicles, and separated the tip of the seventh spine. The bullet was extracted from beneath the skin at the latter spot, its force having been no doubt exhausted by the resistance of the firm neural arches supported by the weight of the man's body. Symptoms of total transverse lesion of the cord followed, and the patient died at the end of fifty-four days. The bone had not apparently been sufficiently depressed to exert continuous pressure, but the cord was diffluent and actually destroyed over an area corresponding with the fourth, fifth, sixth, and seventh dorsal segments. I saw no instance of wound of the _neural arch_ from a direct shot in the back in any of our men, neither was I ever able to detect an injury to the articular processes as a localised lesion. Injuries to the _centra_ were very frequent, but differed extraordinarily in their importance. Perforation by bullets travelling at a relatively low grade of velocity, but still one sufficient to allow them to pass through the body, produced in many instances no symptoms whatever when the track did not lie in immediate contiguity to the spinal canal or perforate it. In all the wounds which I had the opportunity of examining post mortem, the fracture was of the nature of a pure perforation of the cancellous tissue of the centrum, with no comminution beyond slight splintering of the compact tissue at the aperture of exit. In one instance the bullet passed in a coronal direction so close to the back of the centrum as to leave a septum of only the thickness of stout paper between the track and the spinal canal. In this case signs of total transverse lesion were present. I never happened to meet with a case in which the canal was encroached upon from the front by displaced bone. In some cases at the end of six weeks there was difficulty in determining the position of the openings, and section of the bone was necessary in order to assure oneself as to the direction of the track. In some instances the centra were pierced in the coronal direction with varying degrees of obliquity; in others the direction was more sagittal; in two of the latter the bullet was retained in the spinal canal. The tracks were sometimes confined to one vertebra, but often implicated two. In others the bullet passed longitudinally through the thorax, grooving or perforating one or more centra. The accompanying evidences of nerve injury varied from nil to those of pressure or irritation of the nerve roots, transient signs of spinal concussion, signs of contusion and hæmorrhage, or to evidence of total transverse lesion. Instances of all these conditions will be quoted under the heading of injuries to the cord or nerves. _Signs of injury to the vertebræ._--Separation of the spinous processes was often indicated by slight deformity, either evident or palpable, local pain, tenderness, mobility, and crepitus. In some cases these local signs were reinforced by evidence of cord injury. Fractures involving the laminæ differed merely in the degree to which the above signs were developed. Fractures of the transverse processes were generally only to be assumed from the position and direction of the wounds, the assumption being sometimes strengthened in probability by evidence of injury to the cord and nerves. Fractures of the centra were also frequently only to be assumed from the direction of the wound tracks, and possibly from evidence of nerve injury. When no paralysis supervened, interference with the movements of the back, or pain, was so slight as to be inappreciable, especially in the presence of concurrent injury to other parts, which was seldom absent. I only once saw any angular deformity from this injury, and that slight, and not apparent before the end of three weeks. In this particular a very striking difference exists between injuries from small-calibre bullets and larger ones such as the Martini-Henry. In the only instance of Martini-Henry fracture of the spine that came under my notice, the centrum was severely comminuted and deformity was obvious. Still, as in so many particulars, the difference was only one of degree, since comminution of the centra in gunshot wounds has always been observed to be slight in nature compared with what is met with in the compression fractures of civil life. A few words will suffice to dismiss the questions of diagnosis, prognosis, and treatment of the above injuries. The diagnosis depended on attention to the signs above indicated, the prognosis almost entirely on the concurrent injury to the nervous system, which will be considered later, and the treatment consisted in enforcing rest alone. INJURIES TO THE SPINAL CORD ACCOMPANYING SMALL-CALIBRE BULLET WOUNDS OF THE VERTEBRÆ _Anatomical lesions._--In introducing the subject of the nature of the lesions of the spinal cord and membranes, I should again enforce the statement that their character and degree, in comparison with the slight accompanying bone damage, are pathognomonic of gunshot wounds, and that these characters find their completest exemplification in injuries produced by bullets of small calibre, endowed with a high grade of velocity. Again, that the varying degrees of damage depend comparatively slightly on the position of the bone lesion, apart from actual encroachment on the canal, while the degree of velocity retained by the bullet at the moment of impact is all-important. In no other way are the divergent results to be explained which follow an apparently identical injury, in so far as extent, position, and external evidence of damage to the spinal column are concerned. Injuries to the nerve roots of the nature of concussion and contusion, are dealt with in Chapter IX. _Pure concussion_ of the spinal cord may, I believe, be studied from a better standpoint in the case of small-calibre bullet injuries than in any others, since in many instances it is, I think, possible to exclude any complications such as wrenches and strains of the vertebral column, and ascribe the symptoms to the pure effect of extreme vibratory force communicated to the cord by its enveloping bony canal. The condition must be considered under the two headings of slight and severe. In _slight concussion_ the usually transient effects of the injury, and its happy tendency not to destroy life, place us in a state of uncertainty as to the occurrence of anatomical changes, since no opportunity of post-mortem examination occurred. The clinical condition included under this term corresponds with that implied in 'spinal concussion' in civil practice. One point of extreme interest, whether the subjects of small-calibre bullet spinal concussion will in the future suffer from the remote effects common to similar sufferers in civil life from other causes such as railway collisions, still remains for future determination. An ample field for such observations has at any rate been created by the present war. In _severe concussion_ a far more highly destructive action is exerted. This condition may be followed by complete disorganisation of the cord, accompanied or not by multiple parenchymatous hæmorrhages into its substance. Either or both of these pathological conditions are produced by the impact of the bullet with the spine, given a sufficiently high degree of velocity, and it is difficult to separate clinically the resulting symptoms. This is a matter perhaps of less importance, since it stands to reason that a vibratory force, capable of rupturing the spinal capillaries, would at the same time damage the nervous tissue. In speaking of concussion of this degree, it should be clearly recognised that a general condition, such as is indicated by the use of the term 'concussion of the brain,' is in no wise implied. The condition is really far more nearly allied to one of contusion, a strictly localised portion of the spinal cord undergoing the destructive process which affects the segments below only in so far as it interrupts the normal channels of communication with the higher centres. Case 102 is an instance of such a lesion, the post-mortem examination showing clearly that the spinal canal was not encroached upon by the bullet. The cord in this instance appeared little changed macroscopically, and this fact was observed in other instances, both during operations and post mortem. _Contusion._--This condition is very closely allied to the last. In cases 101 and 103 the spinal canal was as little encroached upon as in 102, but the bullet struck the somewhat elastic neural arch in each case, and post mortem an adhesion between the cord and the enveloping dura opposite the point at which impact of the bullet was closest suggests that, in spite of the escape of the bone from fracture, it may have been momentarily depressed to a sufficient degree to contuse the cord, or the latter may have suffered a _contre-coup_ injury. For these reasons the inclusion of the cases as instances of pure concussion is not warranted. In both Nos. 99 and 100 the neural arch had actually suffered fracture, and although the bone was not depressed or exercising pressure at the time of the autopsies, it was no doubt driven in temporarily at the moment of impact of the bullet. At the post-mortem examinations of injuries of this nature it was common to find one to four segments of the spinal cord completely disorganised. At the end of some five weeks, the common duration of life, the structure of the cord was represented by a semi-diffluent yellowish material, the consistence of which was so deficient in firmness as to allow the partial collapse of the membranes covering the affected portion, so as to exhibit a definite narrowing when the whole was held up (see fig. 79). In such cases traces of extra- or intra-dural hæmorrhage sometimes still persisted. _Hæmorrhage._--This occurred as surface extravasation and in the form of parenchymatous hæmorrhages. I saw the former both in the extra-dural and peri-pial forms, but never in sufficient quantity to exert a degree of pressure calculated to produce symptoms of total transverse lesion. Here again, however, it is difficult to speak with confidence since the conditions which regulate the tension within the normal spinal canal are so complicated and liable to variation, that it is very difficult to estimate the effect of any given hæmorrhage discovered. My friend Mr. R. H. Mills-Roberts described to me one fatal case under his care in the Welsh Hospital in which extra-dural hæmorrhage was so abundant as, in his opinion, to have taken a prominent part in the production of the paralytic symptoms. Examples of both extra- and intra-dural (peri-pial) hæmorrhage are afforded by cases 99, 102, and 103; in none was it large in amount or widely distributed. The condition was probably also frequently associated in varying degree with that to be immediately described below. _Intra-medullary hæmorrhage_ (_hæmato-myelia_).--The importance of this condition is lessened in small-calibre bullet injuries by the fact already alluded to, that it is almost invariably accompanied by concussion changes. In one instance in which death took place at the end of eight days, partly as the result of concurrent injury, in a man in whom signs of total transverse lesion of the cord were present, the substance of the cord was found to be closely scattered over with hæmorrhages of various sizes and extending for a longitudinal area of some three inches. As to the frequency with which hæmorrhage into the substance of the cord occurred, I regret to be unable to give an opinion. In the late post-mortem examinations I witnessed, a yellow discoloration of the softened cord was the only macroscopic evidence of hæmorrhage. Hæmorrhages of this nature may, however, account for the grave paralytic symptoms in some cases of partial or total transverse lesion not due to direct compression or laceration. The conditions of concussion, contusion, or hæmatomyelia were, I believe, responsible for at least nine-tenths of the cases in which a total transverse lesion was indicated by the symptoms. The extreme importance of realising this fact and the rarity of the production of symptoms by continuing compression both from the prognostic and the therapeutic point of view is obvious. The analogous injuries termed generally in Chapter IX. nerve contusion, although frequently accompanied by tissue destruction, may be followed by reparative change, and are capable of complete or almost complete spontaneous recovery; while the lesions in the spinal cord are permanent, and complete recovery is only witnessed in the parts affected by the remote pressure or irritation from blood extravasation, or in those influenced by concussion. I include below short abstracts of all the cases of lesion of the spinal cord which terminated fatally, in which I had the opportunity of witnessing the post-mortem conditions. In a considerable proportion of the cases at the end of six weeks the spinal cord was softened over an area of from two to four segments in such degree as to have practically lost all continuity. Although the autopsies were made on patients who had died slowly and in summer weather, often twelve to sixteen hours after death, I think it can be but fair to assume, when the consistency of the remaining portion of the spinal cord is considered, that the softening was only in slight degree if at all exaggerated by post-mortem change. Again symptoms of secondary myelitis and meningitis had been observed in some of the fatal cases prior to death. I had but one opportunity of observing a case in which a retained bullet exercised compression, and none in which this was due to displaced bone fragments. I also only once came across a case of complete section, but no doubt both bone pressure and section may have occurred with greater frequency amongst patients dying on the field or shortly after. The case of section is illustrated in fig. 80. It will be noted that, although the section is complete, the bullet lies to one side of the canal, and hence the bullet, as fixed in its course by the bone of the centrum, directly struck but half of the whole width of the cord. It was striking how little secondary change in the cord had occurred in the neighbourhood of the spot of division. This well illustrates the comparatively slight vibratory effect of a bullet travelling with a degree of velocity insufficient to completely perforate the vertebral column. _Symptoms of injury to the spinal cord._--In _slight spinal concussion_ these exactly resembled those of the more severe lesions, except in their transitory nature. They consisted in loss of cutaneous sensibility, motor paralysis, and vesical and rectal incompetence. The phenomena persisted from periods of a few hours to two or three days, return of function being first noticeable in the sensory nerves, and often with modification in the way of lowered acuteness, or minor signs of irritation, such as formication, slight hyperæsthesia or pain, pointing to a combination with the least extensive degrees of hæmorrhage; later, motor power was rapidly regained. The subjects of such symptoms often suffered from weakness and unsteadiness in movement for some days or weeks; a sharp line of discrimination between such cases and those described in the next paragraphs is manifestly impossible. _Spinal hæmorrhage._--The symptoms of this condition developed differently according to whether concurrent concussion existed. Occasionally very typical instances of pure hæmorrhage were observed with transient symptoms:-- (96) A private in the Yorkshire Light Infantry was wounded at Modder River; the bullet entered between the eleventh and twelfth ribs, just posterior to the left mid-axillary line, emerging in the posterior axillary fold, at its junction with the right side of the trunk. On the second day after the injury the lower extremities became drawn up, the knees and hips assuming a flexed position, and this was followed shortly by the advent of complete motor and sensory paraplegia, accompanied by retention of urine. Two days later, the patient again passed water normally, and gradual and rapid return of both sensation and motor power took place. At the end of fourteen days no trace of the condition remained, and the patient was shortly after sent home. The symptoms, however, were rarely so simple as in this example; it was very much more common to meet with an admixture of signs of primary concussion, or at any rate symptoms of radiation. The following is an extreme but excellent example of more complicated and prolonged effects: (97) A lance-corporal of the Black Watch was wounded at Magersfontein at a range of from 400 to 500 yards. The bullet entered over the left malar bone 2-1/2 inches from the outer canthus, while the aperture of exit was 2-1/4 inches above the inferior angle of the right scapula, 3/4 of an inch anterior to its axillary margin. Very shortly after the injury complete motor and sensory paralysis developed in both upper extremities, followed by the development of a similar condition in the left lower limb, and retention of urine and fæces, but the latter unaccompanied by the marked abdominal intestinal distension so characteristic in cases of total transverse lesion. The right side of the chest continued to work well, but the intercostals of the left side were paralysed. No disturbance of the normal action or condition of the pupils was noted. After the first few days the condition began to improve. Three weeks later, the chest was moving symmetrically and well, sensation and motor power had returned in considerable degree in the left lower extremity, with marked increase in both the plantar and patellar reflexes; sensation had returned in both upper extremities, a slight amount of motor power was regained in the right, but the left remained entirely flaccid and incapable of movement. At the end of a month power was regained over both bladder and rectum, some slight movement of the left thumb was possible, and a certain degree of hyperæsthesia developed over the back of the forearm. At the end of six weeks there was little further alteration, but that in the direction of improvement. There was some wasting of the muscles of the left upper extremity, and this was most marked in the muscles supplied by the ulnar nerve. At the end of ten weeks the patient had been up some days; he could stand and walk, but was unable to rise from the sitting posture without help. The plantar and patellar reflexes were much exaggerated, and there was ankle clonus, most marked in the left limb. The right upper extremity was normal, but weak; there was wrist-drop on the left side and the deltoid was wasted and powerless; on the other hand the fingers could be flexed, and although the elbow could not be, there were signs of returning power in the biceps, and some movements of the shoulder could be performed by the capsular muscles. It was remarkable that common sensation was more acute in the left than the right lower extremity, but I attributed this to the remains of hyperæsthesia on the left side. The patient left for home shortly after the last note. In both these cases the absence of marked hyperæsthesia or pain points to medullary hæmorrhage (hæmato-myelia) as the pathological condition produced by the injury. In this particular they contrast well with case 94 quoted on page 315, where the degree of both hyperæsthesia and pain indicated a combination of pressure and irritation of the nerve roots by surface hæmorrhage on the affected side. In case 97 the persistence for four weeks of paralysis of the bladder and rectum suggested medullary hæmorrhage in addition, while the return of patellar reflex in the paralysed limb negatived the occurrence of an extensive destructive lesion. In view of the extreme interest of these cases I will shortly detail one other in which the cauda equina alone was affected. I must confess my inability to place the case definitely in the category either of concussion or medullary hæmorrhage. As so often happened, both conditions probably took part in the lesion. The immediate development of the primary symptoms is no doubt to be referred to concussion, while the patchy nature of the prolonged lesion and gradual recession of the symptoms point to the presence of hæmorrhages. We find here the link most nearly connecting the spinal cord and the peripheral systemic nerves. Such a case goes far to show that the condition which I have in the next chapter often referred to as nerve contusion may in fact be produced by an injury far short of actual contact. (98) A trooper in the Imperial Yeomanry, while advancing in the crouching attitude, was struck by a bullet from his left front, at an estimated distance of 300 yards. The bullet traversed the right arm anteriorly to the humerus, entered the trunk in the line of the posterior axillary fold, 1-1/2 inch below the level of the nipple, crossed the thoracic and abdominal cavities, deeply striking the lumbar spine, and finally lodged beneath the skin over the venter of the left ilium. The skin was broken, but the force of the bullet was not sufficient to cause it to pass through, and it was later expressed from the wound by the surgeon. The bullet was a Mauser, and not in any way deformed, although it must at any rate have struck the spine and perforated the ilium. Immediate paraplegia resulted, both sensation and motor power were completely abolished, but there was no trouble either with the bladder or rectum. No symptoms of injury to either thoracic or abdominal viscera were noted. Three days after the injury sensation and some return of motor power were observed in the left extremity, and some power of movement in the toes of the right foot. During the next eight weeks steady but slow improvement took place; during the last three weeks of this period he made the voyage to England. Ever since the injury some elevation of temperature was noted, a rise at night to 100° or at times to 102°; for this no definite cause was discovered. In the tenth week the condition was as follows: The temperature has become normal. The patient has lost flesh to a considerable extent since the reception of the injury. The lower extremities are much wasted, especially the peroneal muscles. Patellar reflexes can be obtained, but the knee jerks are uncertain. Unevenly distributed paralysis exists in both lower extremities. Left--Sensation fairly good throughout. Quadriceps very weak; does not react to electrical stimulation. Calf muscles act fairly. Anterior tibial and musculo-cutaneous groups are paralysed. Right--Quadriceps acts better than on left, muscles below the knee paralysed, and in the same area there is complete absence of sensation. The patient complains of shooting pains in both legs, and there is some deep muscular tenderness. Three weeks later an abundant crop of vesicles appeared over the front of the right thigh and leg, above and below the knee. Sensation in the limb at the same time returned to a considerable degree, anæsthesia persisting on the outer aspect of the thigh only. At the end of four months very considerable improvement had taken place, but there was no return of motor power in the right leg, or the muscles supplied by the peroneal nerve in the left leg. There was some general oedema of the legs, especially of the right, possibly in connection with the herpetic eruption which was now disappearing. Muscular tenderness had disappeared. There was also definite improvement in the size and tone of the peroneal muscles, although no motor power was regained. At the end of five months, slight gradual improvement was still taking place, but the loss of power was nearly as extensive as when the last note was taken. The skin of the right leg was glossy, that of the left apparently normal. At times some hyperæsthesia of the soles was noted, and the plantar reflex was very brisk. The right anterior tibial and musculo-cutaneous groups of muscles reacted to the strongest faradic current, not to any galvanic current below 20-25 m.a., contraction very sluggish. The same muscles in the left leg also reacted to the strongest faradic current, but only locally, with no sort of effect on the tendons. Similar contractions could be induced in the right quadriceps, but none in the left (Dr. Turney). Appreciation of heat and cold applied to the skin was fair, but, in the case of heat, distinctly slow in the right leg and foot. At the end of seven months improvement was still taking place; the patient could now stand, walk a little with crutches, and even ascend and descend a staircase. * * * * * _Severe concussion, contusion, or medullary hæmorrhage producing signs of total transverse lesion, and complete transverse section._--The symptoms of these conditions will be taken together, because, with very slight variations, they may be considered as lesions of equal degree as to severity, bad prognosis, and unsuitability for active interference. All were characterised by the exhibition of the same essential phenomena, symmetrical abolition of sensation and motor power on either side of the body, absence of any signs of irritation in the paralysed area, and loss of patellar reflex. In a small number of the cases of medullary hæmorrhage some return of sensation was observed prior to death; in a still smaller, traces of motor power, and in one or two irritability of the muscles or feeble reflexes pointed to the fact that destruction of the cord was not absolute. As abstracts of a series of cases are appended on page 330, it is only necessary to add a few remarks as to any slight peculiarities which seemed directly dependent on the mode of causation. It may be first stated that these severe injuries were accompanied by signs of a very high degree of shock. In fact, the shock observed in them was more severe than in any other small-calibre bullet injuries that I witnessed. The patients lay still with the eyes closed, great pallor of surface, sometimes moaning with pain, the sensorium much benumbed, or occasionally early delirium was noted. The pulse was small, often slow and irregular, and the respiration shallow. The originally quiet state was often changed to one of great restlessness of the unparalysed part of the body, with the appearance of reaction. The degree of primary pain varied greatly, but as a rule it was considerable; in some cases it was excruciating in the parts above the level of the totally destructive lesion, and commonly of the zonal variety. A hyperæsthetic zone at the lower limit of sensation usually existed. In the majority of the cases pain must have depended on meningeal hæmorrhage. In one of the cases related, positive evidence was offered as to this particular by the autopsy, although this was made as long as six weeks after the original injury, since no other source of pressure or irritation was discovered. When I first saw this patient some twenty-four hours after the injury he was moaning with pain, although a strong and plucky man; I hastened to give him an injection of morphia, and assured him that it would relieve his suffering: as I left I heard him say to his neighbour: 'That is no use; they gave me three last night, and I was no better,' and his remark proved true. In high dorsal and cervical injuries the temperature rose high, in one case to 108° F.; I had no opportunity, however, of observing the temperature in any case immediately before and after death. During the hot weather the profuse sweating of the upper part of the body contrasted very strongly with the dry skin of the paralysed part. The heart's action was often particularly irregular in the dorsal injuries, and the respiration slow and irregular; as these cases, however, were often complicated by severe concurrent injuries to internal organs, the irregularities could hardly be ascribed to the spinal-cord lesion alone. In cases of pure diaphragmatic respiration, the rate did not as a rule exceed the normal of 16 or 20 to the minute, and it was quite regular; this was noted soon after the injury and persisted throughout the course of the cases. As is usually the case, both respiration and the heart's action were most embarrassed in the cases in which abdominal distension was a prominent feature. In some of the neck cases the Cheyne-Stokes type of respiration was very strongly marked. In cases of low dorsal injury intestinal distension was extreme, and I think more troublesome than the same condition as seen in civil practice. The distension was accompanied by most persistent vomiting, continuing for days, and in the cases that lived for some time severe gastric crises of the same type occurred in some instances. Priapism was a common symptom; but, as is seen from the cases quoted, was rarely due to any gross direct laceration of the cord. Trophic sores were both early to develop, and extensive; primary decubitus occurred in all the cases I saw, and steady extension followed. In one case a remarkable symmetrical serpiginous ulceration developed in the area of distribution of the cutaneous branches of the external popliteal nerve on the outer side of the leg. The paralysis in nearly every case was of the utterly flaccid type, and wasting of the muscles was early and extreme. This was occasionally accentuated by the supervention of myelitis. Opportunities for making observations on the quantity of urine secreted were not great, and I can offer no remark as to the occurrence of polyuria. In one rapidly fatal case, however, suppression of urine occurred. (99) _Lumbar region. Transverse lesion._--Range under 1,000 yards. Wound of _entry_ (Mauser), over the seventh rib 1 inch from the left posterior axillary fold; _exit_, over the centre of the right iliac crest. Complete symmetrical motor and sensory paralysis of lower extremities, entire abolition of reflexes, retention of urine. On the ninth day there was some return of sensation in the lower extremities, and a cremasteric reflex was to be obtained. A large bedsore had developed over the sacrum. No further change occurred in the lower extremities. The patient became progressively emaciated and exhausted, cystitis persisted, the bedsore deepened. The man eventually developed signs of a large basal abscess in the left lung, and died on the forty-second day. At the _post-mortem_ a fracture of the first lumbar lamina was discovered, with some splintering of the bone; the lumbar spinous process was attached and in its normal position. Opposite the centre of the cauda equina were the remains of a considerable hæmorrhage, both extra- and intra-dural, the nerves appearing somewhat compressed, but of normal consistency. The muscles of the back were infiltrated with putrid pus on both sides. A pulmonary abscess cavity the size of a hen's egg occupied the upper part of the lower lobe of the left lung. The kidneys were congested, and the bladder thickened and chronically inflamed. (100) _Cervico-dorsal region. Total transverse lesion._--Wound of _entry_ (Mauser), to the right of the sixth cervical vertebra: the bullet was removed on the field from the left of the seventh dorsal spinous process, which was somewhat prominent. Complete motor and sensory paralysis extended upwards to the third intercostal space; the breathing was almost entirely diaphragmatic. Retention of urine. Entire abolition of reflexes in lower limbs and trunk. Hyperæsthesia was present in both upper extremities, with a zone of hyperæsthesia around the chest. The patient suffered greatly for some weeks from pain in the hyperæsthetic area, he developed severe cystitis and later incontinence of urine. A large trophic sacral bed-sore steadily increased in depth and size. About ten days before death, which occurred on the fifty-third day from exhaustion and septicæmia, the patient complained of pains in his legs; but there was no return of sensation, motion, or reflexes. At the _post-mortem_, the seventh dorsal spinous process was found to be loose and the laminæ of the fifth, sixth, and seventh vertebræ were separated from the pedicles, and somewhat depressed on the left side. These laminæ were adherent to the dura, as were also a few small separated bony spiculæ. There was no sign of old hæmorrhage. The spinal cord was practically gone between the levels of the fourth and seventh dorsal vertebræ, and diffluent from myelitis up to the third cervical. (101) _Dorsal region; total transverse lesion._--Wound of _entry_ (Mauser), in the left supra-spinous fossa of the scapula; _exit_, between the eleventh and twelfth ribs of the right side. Complete motor and sensory paralysis, with absence of reflexes from mid-dorsal region downwards. Upper intercostals working. Retention of urine, penis turgid. Sensation perfect to lower extremity of sternum. Early trophic sacral bed-sores developed and steadily increased in depth and extent, slighter ones developed on the heels. The paralysis was flaccid throughout. The patient gradually emaciated with fever, and died on the seventy-eighth day. At the _post-mortem_ the wound proved not to have penetrated the thorax, and both the vertebral spines and laminæ were intact, no trace of bony injury being discoverable. Opposite the sixth dorsal vertebra, for a distance of 1-1/2 inch, the cord and dura were adherent, and over the same area the cord was represented by soft custard-like material. There was no sign of old hæmorrhage. (102) _Dorsal region; total transverse lesion; slight extra-dural hæmorrhage._--Wound of _entry_ (Mauser), at the posterior aspect of the right shoulder; _exit_, 2 inches to the left of the spine below the ninth rib. Complete motor and sensory paralysis below the site of the lesion, with absence of superficial and deep reflexes. Retention of urine. Great abdominal distension, pain, and vomiting. Bed-sores over the sacrum developed on the third day; meanwhile the vomiting continued on and off for a week, and very severe girdle pain persisted. One month later when seen at the Base hospital considerable improvement had occurred. Sensation had returned in both lower limbs; but flaccid paralysis persisted and both were wasted, especially the left. There was no return of reflexes in the lower limbs, the urine was passed in gushes, and the patient was cognisant when these occurred. The sacral bed-sores were, however, very extensive and becoming larger and deeper. At the end of the fifth week slight power was regained in the flexors and abductors of the right thigh, and the same muscles of the left limb could be made to contract feebly. Meanwhile the patient suffered with severe fever, accompanied by frequent rigors and profuse sweats; the bed-sore continued to extend, and the urine was foul and contained pus. The patient continued in a similar condition, progressive emaciation and exhaustion taking place, and at the end of six weeks he died. At the _post-mortem_ the bullet was found to have tracked beneath the right scapula, entering the chest by the fifth intercostal space and lacerating the right lung; thence it entered the eighth dorsal centrum and tunnelled both this and the ninth diagonally, to escape beneath the ninth rib. On opening the spinal canal the tunnel was found to be separated only by the compact tissue of the centrum from the cavity, while a thin extra-dural hæmorrhage separated the dura from the bones anteriorly. The spinal cord exhibited no sign of pressure and was firm and continuous, but up to the lower limit of the dorsal region there was septic myelitis and meningitis, the result of pus having tracked up the canal from the sacral bedsore. Suppurative cystitis and pyelitis were present. The patient was the subject of an old urethral stricture which had given rise to trouble during treatment. (103) _Dorsal region; total transverse lesion; slight intra-dural hæmorrhage._--Wound of _entry_ (Mauser), below spine of scapula, close to right axilla; _exit_, 2-1/2 inches to left of tenth dorsal spinous process. Complete motor and sensory paralysis below ensiform cartilage, with well-marked hyperæsthetic zone around trunk. All reflexes absent. Retention of urine. Incontinence of fæces. Bed-sores in sacral region developed during the first two days, and seventeen days later well-developed serpiginous trophic sores developed on the outer side of each leg and continued to increase slowly until death. The paralysis remained of the absolutely flaccid variety. Great emaciation occurred, accompanied by hectic fever, the temperature ranging from normal to 102.5°. During the third week double pleurisy developed. At the _post-mortem_ no bone injury could be detected. The cord and dura-mater were adherent over an area corresponding to the fifth to the eighth dorsal vertebræ, and opposite the seventh the cord was soft and of the consistence of butter. A small intra-dural hæmorrhage was still evident below the main lesion, not extensive enough to give rise to serious compression. General adhesions in each pleura. Cystitis. [Illustration: FIG. 79.--Appearance of Spinal Cord enclosed in membranes in case 103 after removal from the canal. When the membranes were opened a white custard-like substance took the place of the cord. Slight evidence of extra-dural hæmorrhage existed] (104) _Dorsal region; section of cord; retained bullet._--Wound of _entry_ (Mauser), in seventh right intercostal space, 4-1/2 inches from the dorsal spinous processes, oval in outline; bullet retained. Complete motor and sensory paralysis, with absence of reflexes below umbilicus. Retention of urine, incontinence of fæces. Large sacral bed-sore developed rapidly. Right hæmothorax. The patient emaciated rapidly, and for the last fourteen days the temperature ranged to 104°, the bed-sore steadily increasing in size. Death occurred on the forty-second day. At the _post-mortem_ a Mauser bullet was found embedded in the centrum of the twelfth dorsal vertebra. The bullet was slightly curved; its anterior extremity had passed across the spinal canal, and wounding the dura posteriorly rested against the left lamina. The plating of the mantle of the bullet was stripped from half the area of the tip. The dura was not adherent, and the cord was softened for half an inch above the point of section; above this it was normal, the vessels coursing normally to the softened spot. Below the point of section the cord was blanched, but offered no other macroscopic evidence of disease. No evidence of either intra- or extra-dural hæmorrhage was detectible. [Illustration: FIG. 80.--Complete division of Spinal Cord. The bullet is retained, and from its position can be seen to have struck the right half of the cord only. The nickel plating of half of the tip of the bullet is stripped off. Case No. 104] The right pleura contained a large quantity of dark cocoa-like fluid. Extensive adhesions were present in both pleural cavities. The spleen was much enlarged. At the base of the bladder a large submucous hæmorrhage had occurred, the blood-clot had assumed a dark orange colour, and on first opening the viscus the appearance was that of a mass of fæces. The mucous lining elsewhere was slaty grey, with small hæmorrhages. The kidneys were large, but no abscesses or pyelitis were present. (105) _Cervico-dorsal region; total transverse lesion._--Wound of _entry_ (Mauser), opposite right sixth cervical transverse process; _exit_, on left side of third dorsal spinous process. Slight grasping power was present in the hands, and the patient could hold his arms across his chest. Complete motor and sensory paralysis, with absence of all reflexes below. The pupils were moderately contracted. Retention of urine. On the second day blebs appeared on each buttock, and the patient complained of very severe pain in the neck: the temperature rose to 103°, and on the third day he died suddenly. No _post-mortem_ examination was made. I observed two similar cases in the Field Hospital at Orange River, the patients dying on the third day; pain and high temperature were prominent symptoms in both. In one patient early delirium was present. (106) _Dorsal region; Martini-Henry wound._--Wound of _entry_, oval, 1 inch × 3-1/4 inches; long axis obliquely crossing infra-spinous fossa of right scapula; bullet retained (Martini-Henry). Spine of third dorsal vertebra loose, and a distinct thickening to its right side. Complete symmetrical paralysis extending up to upper extremities. No sensation on surface of trunk below cervical area. Respiration entirely diaphragmatic. Retention of urine, penis turgid. Total absence of reflexes, superficial and deep. Reddening of buttocks, but no bullæ. General hyperæsthesia of upper extremities, with severe spasmodic attacks of pain. On the third day an exploration was decided upon, in view of the local deformity, and the severe pain in the upper extremities. The third dorsal spine was found to be loose, as a result of bilateral fracture of the neural arch; the bullet had crossed the right limit of the spinal canal, and destroyed the body of the vertebra, and passing onwards had entered the left pleural cavity, into which air entered freely from the operation wound. The patient was relieved from his pain by the exploration, and lived four days. On the second day after operation, however, the temperature rose to 107°, while on the last two days the temperature was normal in the mornings, rising to 105° in the evenings. No alteration resulted in the trunk symptoms. _Diagnosis._--The pure question of the fact of injury of the spinal cord needs no discussion; but it is necessary to make some remarks on the discrimination between concussion, contusion and hæmorrhage, meningeal and medullary hæmorrhage, the latter condition and compression, and on partial and complete severance of the cord. The sharp discrimination of cases of concussion from those of slight medullary hæmorrhage was necessarily impossible. I think the only points of any importance in diagnosing pure concussion were the transitory nature of the symptoms, and the uniformity of recovery, without persistence of any signs of minor destructive lesion. In medullary hæmorrhage the tendency for a certain period was towards increase in gravity in the signs. It goes almost without saying that the latter point was seldom accurately determined in patients struck on the field of battle; these perhaps lay out for hours before they were brought in, and when they were placed in the Field hospital the rush of work did not usually allow the careful observation necessary to clear up this difference in the development of the symptoms. Nevertheless it is preferable to consider the cases in which transitory symptoms persist for a period of hours, or even a couple of days, as instances of pure concussion, unless the existence of this condition can be disproved by actual observation. Extra-medullary hæmorrhage, accompanied by only slight encroachment on the spinal canal, certainly results with some frequency from small-calibre wounds. Some of the quoted cases show this decisively by _post-mortem_ evidence, others by such clinical signs of irritation as pain and hyperæsthesia. I think its presence may also be assumed in cases of total transverse lesion due to medullary hæmorrhage or severe concussion, accompanied by well-marked pain and hyperæsthesia above the level of paralysis. As affecting treatment, however, determination of its presence is of small importance. The important conditions for discriminative diagnosis are those of local compression, actual destructive lesion, whether from concussion changes, contusion, or medullary hæmorrhage, and partial and total section of the cord. First, with regard to compression of the cord, the possible sources are three; (i) extra-dural hæmorrhage, which may, I think, be dismissed with mention as rarely capable of producing severe symptoms. (ii) The displacement of bone fragments. This is of less importance than in civil practice, because an injury by a bullet of small calibre, capable of seriously displacing fragments, has probably at the same time produced grave changes in the cord. In the presence of severe immediate symptoms we may tentatively assume that a simultaneous destructive lesion has been produced. In such injuries pain, combined with a tendency to improvement in the paralytic symptoms and return of reflexes, is the only point in favour of bone pressure, unless considerable deformity of the spinal column can be detected by palpation or examination with the X-rays. (iii) Pressure from the bullet. This is the most important form of compression, because the mere fact of retention of the bullet is evidence of a low degree of velocity, and therefore opposed to the existence of the most severe form of intramedullary lesion. In a case of apparent transverse lesion with retained bullet, shown to me at No. 3 General Hospital by Mr. J. E. Ker, the pain was very severe, and so greatly aggravated by movement that an anæsthetic had to be administered prior to the renewal of some necessary dressings. The general condition of this patient precluded a projected operation, and after death the bullet was found to be pressing laterally upon a cord not materially altered on macroscopic inspection. In the case of retained bullet recorded (No. 104), the slight degree to which the severed ends of the cord appeared altered has been already remarked upon. Beyond this we are helped by the position of the aperture of entry, and its shape, as evidence of the direction in which the bullet passed, the presence of pain, and positive proof may be obtained by examination with the X-rays. Lastly, we come to the discrimination of total or partial section, destruction by vibratory concussion or contusion, and severe intramedullary hæmorrhage. Except in the case of partial section with localised symptoms, which must be rare, I believe this to be impossible from the primary symptoms, although some indication of possible encroachment on the canal may be obtained from careful consideration of the course of the wound, as evidenced by the position and shape of the openings, the position of the patient's body at the time of reception of the injury being taken into consideration. Later we may get some aid from the possible improvement in the symptoms in the case of hæmorrhage. In cases with signs of total transverse lesion, however, the discrimination of the conditions is of little practical importance, since either is equally unfavourable and unsuitable for surgical treatment. In closing these remarks reference must be made to the occasional occurrence of paraplegic symptoms of an apparently purely functional nature. I saw these on one or two occasions, of which the following is a fair example. A man was wounded in the lower extremity and fell. When brought into the hospital he complained of loss of power in the legs and inability to straighten his back. No very definite evidence was present of serious impairment either of motor or sensory nerves, and the man was got up and walked with crutches. While moving about the hospital camp, another man pushed him down, and the patient then became completely paraplegic. He was placed in bed, and the next day moved his limbs without any difficulty, and gave rise to no further anxiety. _Prognosis._--In slight concussion the importance of prognosis is as to remote effects, and upon this no opinion can be given at the present time. The same may be said concerning cases in which transient symptoms followed the slighter degrees of surface and medullary hæmorrhage. In the case of the latter, however, I think it would be rash to give a too confident opinion as to the future non-occurrence of secondary changes. Severe concussion is probably irrecoverable. Meningeal hæmorrhage of either form is one of the slighter lesions, and less dangerous, both as an immediate condition and as to the probabilities of after trouble. None the less the possibilities of secondary chronic meningitis, or chronic trouble from adhesions, must be kept in mind. Cases of medullary hæmorrhage with incomplete signs are favourable in prognosis, as far as life is concerned; as to complete recovery, however, this is hardly possible; in many cases serious functional deficiency at any rate will remain, while in others the healing of the lacerated tissue and subsequent contraction can scarcely fail to influence unfavourably an already imperfect recovery. I think it must be a rare occurrence for pressure from bone fragments to be able to be regarded as a favourable prognostic condition, since in the very large majority of cases the velocity of the bullet causing the injury will have been such as to inflict irreparable damage on the cord. Still, cases may occasionally be met with where the velocity has been sufficiently low, or contact with the bone slight enough, to allow of the comparative escape of the cord. In this relation cases in which the bullet is retained, especially if the symptoms of transverse lesion are incomplete, may be regarded as relatively favourable. Cervical and high dorsal injuries, as in civil practice, offered the worst prognosis. In cases in which symptoms of total transverse lesion were present, as far as my experience went, it was, however, only a matter of importance as to the prolongation of a miserable existence. All the patients eventually died; those with higher lesions at the end of a few days; the lower ones, at the completion on an average of six weeks of suffering. The actual causes of death resembled exactly those met with in civil practice, except in so far as it was more often influenced or determined by concurrent injuries, a complication so characteristic of modern gunshot wounds. Thus exhaustion, septicæmia from absorption from suppurating bed-sores or from severe cystitis, secondary myelitis, and pulmonary complications, carried off most of the patients. _Treatment._--The general treatment of the cases demanded nothing special to military surgery, except in so far as it was modified by the disadvantage to the patient of necessarily having to be transported, often for some distance. The ill effects of this, particularly in cases of hæmorrhage, are obvious, but in so far as fracture was concerned the question of transport did not acquire the importance that it does in civil practice, since the nature of the fractures and their strict localisation did not render movement either painful or particularly hurtful. It was indeed striking how little pain movement, made for the purposes of examination, caused these patients. The treatment of bed-sores, cystitis, or other secondary complications possessed no special features. The importance of insuring rest in the early stages of the cases of hæmorrhage is self-evident; hence, if the possibility exists of not moving the patient, its advantage cannot be too strongly insisted upon. Again, if transport is inevitable, the shorter distance that can be arranged for the better. It should be borne in mind, also, that from the peculiar nature of causation of the injuries, stretcher or wagon transport for short distances is preferable to the vibratory movements of a long railway journey. Beyond this the administration of opium, and in some cases the assumption of the prone position, are both useful in the recent or possibly progressive stage of hæmorrhage. Lastly, as to active surgical treatment by operation. In no form of spinal injury is this less often indicated, or less likely to be useful. It is useless in the cases of severe concussion, contusion, or medullary hæmorrhage which form such a very large proportion of those exhibiting total tranverse lesion, and equally unsuited to cases of partial lesion of the same character. Extra-medullary hæmorrhage can rarely be extensive enough to produce signs calling for the mechanical relief of pressure; the section of the cord cannot be remedied. In one case with signs of total transverse lesion, in which a laminectomy was performed, no apparent lesion was discovered, and this would frequently be the case, since the damage is parenchymatous. The experience was indeed exactly comparable to that which followed early exposure of the peripheral nerves. Only three indications for operation exist. 1. Excessive pain in the area of the body above the paralysed segment; operation is here of doubtful practical use, except in so far as it relieves the immediate sufferings of the patient. 2. An incomplete or recovering lesion, when such is accompanied by evidence furnished by the position of the wounds, pain, and signs of irritation of pressure from without, or possibly palpable displacement of parts of the vertebra, that the spinal canal is encroached upon by fragments of bone. 3. Retention of the bullet, accompanied by similar signs to those detailed under 2. In both the latter cases the aid of the X-rays should be invoked before resorting to exploration. Operation, if decided upon, in either of the two latter circumstances, may be performed at any date up to six weeks; but if pressure be the actual source of trouble, it is obvious that the more promptly operation is undertaken the better for early relief and ulterior prognostic chances. In only one case of the whole series I observed did it seem possible to regret the omission of an exploration. CHAPTER IX INJURIES TO THE PERIPHERAL NERVE TRUNKS The occurrence of these injuries has undoubtedly increased in frequency with the employment of bullets of small calibre, and no other class of case more strikingly illustrates the localised nature of the lesions produced by small projectiles of high velocity. Again, no other series of injuries affords such obvious indications of the firm and resistent nature of the cicatricial tissue formed in the process of repair of small-calibre wounds, and in none is the advantage of a conservative and expectant attitude so forcibly impressed upon the surgeon. Implication of the nerves may be primary, or secondary to an injury which left them originally unscathed. _Nature of the anatomical lesions._--In degree these vary in mathematical progression, but the extent of the lesion is not always readily differentiated by the early clinical manifestations, and again the actual damage is not to be estimated by the gross apparent anatomical lesion alone; but, in addition, consists in part in changes of a less easily demonstrable nature, varying with the velocity with which the bullet was travelling and the consequent comparative degree of vibratory force to which the nerve has been subjected. In these injuries, as in those of every part of the nervous system, the degree of velocity appears to gain especial importance both in regard to the general symptoms and the local effect on the functional capacity of the nerve. This is perhaps a fitting place for the introduction of a few further remarks as to the significance of the term 'concussion' in connection with the injuries produced by bullets of small calibre, since the most striking exemplification of the results following the transmission of the vibratory force of the projectile is afforded by the behaviour of the comparatively densely ensheathed and supported peripheral nerves. As already pointed out in Chapters VII. and VIII. the chief concussion effects on the nervous tissue of the brain and spinal cord are of a destructive nature, far exceeding those accompanying the injuries designated by the same term seen in the ordinary accidents met with in civil practice, and this damage is comparatively localised in extent. In the case of the peripheral nerves I have still employed the terms 'concussion' and 'contusion' to designate certain groups of symptoms and clinical phenomena, but any sharp distinction between the two conditions on a morbid anatomical basis is impossible. The results of severe vibratory concussion may, in fact, be more generally destructive than those of contusion, and the subsequent effects more prolonged. A certain length of the affected nerve is apparently completely destroyed as a conductor of impulses, the connective-tissue element alone remaining intact. Under these circumstances a nerve, the subject of the most serious degree of vibratory concussion, which, if cut down upon, may exhibit no macroscopic change, may take a longer period to recover than one in which the presence of considerable local thickening points to direct contact with the bullet, with resulting hæmorrhage into the nerve sheath and perhaps partial gross rupture of nerve fibres. The therapeutic and prognostic importance of the above remarks, if correct, is obvious. The course of the nerve is preserved by its intact connective-tissue framework, and ultimate recovery by a regeneration of the nerve fibres is more likely to be complete, and will be just as rapid, if nature be relied on and the nerve be left untouched by the hand of the surgeon. It is, I think, undeniable that nerve trunks may escape severe or irrecoverable injury by lateral displacement. The mere fact that the trunk itself may be perforated by a slit in its long axis would suggest the possibility of displacement of the whole structure, and this no doubt occurred with some frequency. Displacement would naturally be most frequent in the case of nerves, such as those of the arm, which run long courses in comparatively loose tissue. In a remarkable case already narrated, an exploratory operation showed the musculo-spiral nerve in the upper part of the arm to have been driven into a loop which projected into, and provisionally closed, an opening in the brachial artery. I. _Simple concussion._--Anatomically, or histologically, no information exists as to the changes which give rise to the often transitory symptoms dependent on this condition. We are reduced to the same theories of molecular disturbance and change which have been invoked to account for similar affections of the central nervous system. The causation of concussion is, however, materially influenced in its degree by the velocity of flight of the bullet and consequent severity of the vibratory force exerted. Hence actual contact of the bullet with the nerves is not necessary for its production, as is seen in the temporary complete loss of functional capacity in the limbs in many cases of fracture, where the vibrations are rendered still more far-reaching and effective as the result of their wider distribution from the larger solid resistance afforded by the bone. The relative density and resistance offered by the different parts of the bone acquire great significance in this relation, since local shock due to nerve concussion is far more profound when the shafts are struck than when the cancellous ends furnish the point of impact. The form of concussion which most nearly interests us in this chapter is that affecting single nerve trunks in wounds of the soft parts alone, and here the passage of the bullet is, as a rule, so contiguous to the nerve that there is difficulty in drawing a strict line of demarcation between such cases and those dealt with in the next paragraph. II. _Contusion._--Clinically this was the form of nerve injury both of greatest comparative frequency and of interest from the points of view both of diagnosis and prognosis. The seriousness of a contusion depends on two factors: first, the relative degree of violence exerted upon the nerve, which is dependent on the force still retained by the travelling bullet; and, secondly, on the extent of tissue actually implicated. The range of fire at which the injury was received determines the importance of the first factor; the second varies with the degree of exactness with which the nerve is struck, and on the direction taken by the bullet. Naturally transverse wounds affect a small area; while an oblique or longitudinal direction of the track may indefinitely increase the extent of injury to the nerve trunk, and hence acquire prognostic significance in direct ratio to the amount of tissue which needs to be regenerated. As to the actual anatomical lesion resulting in the cases which we designated clinically as contusion I can give no information. On many occasions when the symptoms were considered of such a nature as to render an exploration advisable, no macroscopic evidence of gross injury was obtained. It was therefore impossible to draw a definite line of demarcation between such cases and those which we considered merely concussion. It could only be assumed that the vibration transmitted to the nerve had occasioned such changes as to destroy its capacity as a conductor of impressions. In some cases the presence of a certain amount of interstitial blood extravasation was suggested clinically by early hyperæsthesia and signs of irritation; in others the paralysis was of such a degree as to lead to the inference that a complete regeneration of the existing nerve would be necessary prior to the restitution of functional capacity. In a certain proportion of the injuries the development of a distinct fusiform swelling in the course of the nerve pointed to the existence of considerable tissue damage, while in others this was evidenced clinically by early signs of neuritis. III. _Division or laceration._--The varying mechanical conditions affecting the last class of injury play a similar rôle here. Thus the degree of laceration depends on the direction of the wound track, and as all lacerations are accompanied by contusion, the relative velocity retained by the travelling bullet assumes the same importance. I saw every degree of injury to the trunks, from notching to complete solution of continuity, and in some cases destruction and disappearance of pieces from one to two or more inches in length. Such lesions as the latter were most common in the forearm. In this segment of the limbs tracks of varying degrees of longitudinal obliquity are readily produced, whether the patient be in the upright or prone position, since the upper extremities are commonly in forward action whichever position is assumed. The most peculiar form of injury consisted in perforation of the trunk without gross destruction of its fibres, and without in many cases prolonged or permanent loss of functional capacity. I cannot speak with any confidence as to the comparative frequency of occurrence of this form of injury, but judging by the analogous perforations of the vessels, it is probably not uncommon in trunks large enough to allow of its production. The trunk nerves of the arm, and the great sciatic nerve, were probably the most frequent seats of such wounds. As, however, a very short experience of the futility of early interference in the case of nerve lesions warned me against exploration before a date at which observations of this nature were unsatisfactory, I gained less experience on this point than I could have wished. In the case of completely divided nerves the development of a bulbous enlargement on the proximal end was constant, and very marked in degree. I saw few cases in which primary effects could be certainly referred to pressure or laceration by bone spicules, excepting in some fractures of the humerus, and perhaps some injuries of the seventh nerve accompanying perforating wounds of the mastoid process. IV. _Secondary implication of the nerves._--This was a striking characteristic in many at first apparently simple wounds of the soft parts. In such cases it was due to implication of the contiguous trunk in the process of cicatrisation, and its importance varied with the size of the nerve in question. In the smaller sensory trunks it was often evidenced by the occurrence of neuralgic pain, especially liable to be influenced by climatic changes; in the larger, by signs of more or less severe motor, sensory, and trophic disturbance. Musculo-spiral paralysis from implication in, or pressure from, callus in cases of fracture of the humerus was very frequent. This would naturally be expected from the extreme degree the comminution of the bone often reached, and the consequently large amount of callus developed. The effect of cicatrisation of the tissues surrounding the nerves varied somewhat according to the degree of fixation of the individual nerve implicated. Thus if a nerve lay in a fixed bed some form of circular constriction resulted; if, on the other hand, the nerve was readily displaceable, the cicatrix often drew it considerably out of its course; in either case symptoms corresponding with those of pressure resulted. _Symptoms of nerve lesion_.--These differed little in character from those common to such injuries in civil practice, except in the relative frequency with which they assumed a serious aspect. After all in civil practice nerve concussion is most familiar to us in the degree common after knocking the elbow against a hard object, and the same may be said in regard to the allied injury of contusion. It is in small-calibre bullet wounds alone that the occurrence of such severe and sharply localised injury to deep parts as was observed is possible. _Concussion_.--Temporary loss of function was often observed in the limbs, corresponding to the distribution of one or more nerve trunks when wound tracks had passed in their vicinity. Interference with function sometimes amounted to loss of sensation alone: in others to loss of both sensation and motor power. Such symptoms were of a transitory character, lasting for a few days or a week; if both sensation and motion were impaired, sensation was usually the first to be regained. In these cases secondary trouble was not uncommon, since the near proximity of the track to the originally affected nerve offered every chance for implication of the latter in the resulting cicatrix. This sequence was often observed, and its symptoms are described under the heading of secondary implication below. Equally striking were the instances of concussion in the case of the nerves of special sense and their end organs, temporary loss of smell, vision, or hearing being not uncommon, often passing off in the course of a few days with no apparent ulterior ill-effect. One of the most interesting illustrations of the occurrence of concussion was furnished by cases in which complete paralysis of a limb rapidly cleared up with the exception of that corresponding to a single individual nerve of the complex apparently originally implicated. Instances of severe contusion or division of one nerve of the arm, for instance, accompanied by transient signs of concussion of varying degrees of severity in all the others, were by no means uncommon. _Contusion_.--The symptoms of contusion were somewhat less simple, since, in addition to lowering or loss of function, signs of irritation were often observed. In the slighter cases irritation was often a marked feature, as was evidenced by hyperæsthesia and pain combined with loss of power. In cases in which pain and hyperæsthesia were primary symptoms, these were often transitory. I will quote an illustrative case which, though affecting the nerve roots, is characteristic of the effects of slight contusion in the case of the nerve trunks in any part of their course:-- (107) _Contusion of cervical nerve roots_.--Range probably about 1,000 yards. Wounded at Belmont. Aperture of _entry_ (Lee-Metford), immediately posterior to the right fifth cervical transverse process; _exit_, immediately anterior to the space between the third and fourth left cervical transverse processes. The movements of the neck were perfect, there was neither pain nor difficulty in swallowing. Extreme hyperæsthesia was present in both palms and down the front of the forearms. The grip in either hand was weak, this being possibly explained in part by the hyperæsthesia of the palms, as all movements of the upper extremities could be made, although not with full power. On the fourth day the condition was much improved on the left side, and at the end of a week the left upper extremity was normal; the right (side of entry, and therefore exposed to greater force from the bullet) improved more slowly, becoming normal only at the end of three weeks. I observed an identical case of injury to the cervical roots, and many similar instances in injuries of the nerve trunks of the limbs in which the course was exactly parallel. In the more severe, pain was often added to hyperæsthesia. In the most severe cases the signs corresponded in all particulars, except in the early entire loss of reaction of the muscles to electricity, with those of complete section. Loss of sensation and motion was immediate, complete, and prolonged, the limbs being lowered in temperature, flaccid, and powerless. General systemic shock was also severe. In the case either of plexus or multiple contusions, or where the injury was more local, correspondingly complete signs were present in the area supplied by the affected nerves. In the cases in which the contusion was not of extreme degree, hyperæsthesia often developed as a later sign, and was probably due to the irritation of hæmorrhage, when the sensory portion of the nerve began to regain functional capacity. The date of appearance of the hyperæsthesia varied from a few days to a week or later. It might then persist for weeks or many months. In a few instances large blebs rose on the back of the hand, or patches of vesicles appeared over the terminal distribution of the nerve, pointing to early trophic changes. The period of recovery varied greatly; in some instances of very complete paralysis, function was regained and became apparently normal at the end of three or four weeks; in others, even after severe wasting of muscles for weeks, rapid improvement occurred often suddenly, while in some there was no apparent recovery at the end of months. In cases of long-deferred improvement, wasting of the muscles became a very prominent feature; but this without complete loss of reaction of the muscles to electrical stimulation. Recovery of sensation usually preceded by some time that of motion, the former often reappearing in some degree at an early date, and, even if very modified in character, it formed a most useful and valuable aid both in diagnosis and prognosis. When in a position allowing of direct examination, the contused portion of the nerve sometimes developed a palpable fusiform thickening, manipulation of which might give rise to formication in the area of distribution--a favourable prognostic sign. Many of the cases bore a very marked resemblance in character to those in which paralysis results from tight constriction of the limb, as in the arm after the application of an Esmarch's tourniquet. _Laceration._--If incomplete, the signs corresponded very nearly to those of severe contusion, since partial section is impossible without the occurrence of the latter. The condition indeed was only to be distinguished by the partial nature of the recovery, and even this latter might be only more prolonged. The same remarks hold good with regard to perforation of the nerve trunks; but, as regards function, these injuries are not so serious in prognosis as very much more limited transverse divisions or mere notching, and in some cases the disturbance of function was by no means profound or prolonged. Absolute loss of reaction to electrical stimulus from above was the only pathognomonic sign of actual section, unless the position of the nerve was such as to allow of palpation, when the presence of a bulbous end at once settled the difficulty. In many cases of superficial tracks with division of such nerves as the long or short saphenous, the early development of bulbs in the course of the trunks gave positive information, and these were often observed. _Traumatic neuritis._--This was a common sequence of contusion of the nerve itself, or of its subsequent inclusion in a cicatrix or callus. It was evidenced by hyperæsthesia both superficial and deep, pain, contracture, wasting of the muscles, local sweating, and the development of glossy skin. Examples of this condition were seen in the case of nearly every nerve in the body. In frequency of occurrence, degree of severity, and in its selection of individual nerves considerable variation was met with. With regard to the two former points, personal idiosyncrasy, and degree of or peculiarity in the nature of the injury, are the only explanations I can suggest. Perhaps in some instances exposure to wet or cold in the early stages of the injury was of some import. Thus, I saw several severe cases of musculo-spiral neuritis in men who were wounded during the trying and wet march on Bloemfontein. I did not observe that suppuration or wound complications seemed important explanatory moments, as most of the cases occurred in wounds that healed rapidly. With regard to the question of selection; the same nerves that appear particularly liable to suffer from idiopathic inflammations, toxic influences, or to be the seat of ascending changes (e.g. ulnar, musculo-spiral, and external popliteal), were those most often affected by secondary neuritis. Many of the most severe cases I saw were in the musculo-spiral nerve. _Scar implication._--The signs of this most commonly commenced with neuralgia, or painful sensations when such movements were made as to put the cicatrix on the stretch. Although such neuralgia might not be constant, it was often observed to be troublesome when the patients were exposed to cold in sleeping out at night, or to extra fatigue, as in long marches. The results in many cases stopped at this point, but the size and wide distribution of certain nerves rendered even such slight symptoms of importance; while in others well-marked signs of neuritis declared themselves, such as glossy skin, pain, muscular wasting, and paralysis. _Ascending neuritis._--In a few cases I observed very remarkable instances of ascending neuritis, after comparatively slight wounds. I will quote three of these as illustrations and make no further remarks as to the symptoms. It will be observed that one is a case of ulnar, both the others of external popliteal, neuritis:-- (108) _Ulnar nerve: secondary ascending neuritis._--Boer wounded at Elandslaagte. Wound of hand, implicating anterior two-thirds of third metacarpal bone. This bone, together with the middle finger, was removed, and healing took place by granulation slowly. The resulting gap allowed considerable overlapping of the fingers, and shortening of the corresponding digit; the index finger also became flexed as a result of destruction of the extensor tendons. Three months later the man was still in hospital in consequence of the tardiness with which the wound had healed: at this time pain was noted, which became very severe in the whole course of the ulnar nerve; superficial hyperæsthesia and deep muscular tenderness developed, but no wasting. Several crops of herpetic vesicles also developed over the distribution of the radial nerve in the hand. This pain was followed by spastic contracture, first of the ulnar fingers and later of the wrist and elbow, which could only be straightened by the application of considerable force. The limb was, therefore, kept straight by the application of a splint; and warm baths, and a blister applied over the course of the ulnar nerve, were resorted to: under this treatment the condition improved until the patient was well enough to be transferred as a prisoner, and I saw him no more. (109) _Peroneal nerve branches._--Wounded at Colenso. _Entry_, at the anterior margin of the fibula 5 inches above the external malleolus; the track crossed the anterior aspect of the leg obliquely, to its _exit_ 1 inch above the centre of the ankle joint. Incomplete paralysis of the peronei muscles followed, combined with progressive wasting of the whole limb, which at the end of a month was marked, and then commenced to improve. (110) In a second case the wound took a similar course in the centre of the leg, crossing the line of the branches of the musculo-cutaneous nerve. Motor paralysis of the peronei followed, together with general lowering of tactile sensation in the musculo-cutaneous area. _Traumatic neurosis._--In connection with the cases just quoted, mention must be made of the fact that the functional element was often somewhat prominent. The influence of this factor was not to be neglected in case 108; again, its presence was a feature in cases 132 and 134, of injury to the sciatic nerve and of peripheral injury to the seventh nerve (p. 355). A remark has been made as to the occurrence of functional paraplegia on p. 337. Again, in the case of the organs of special sense. Case 66, of injury to the occipital lobes, showed that a mixture of organic and functional phenomena might be a source of error, even in the determination of the visual field in the subject of an undoubted destructive lesion. On more than one occasion an injury was accompanied by loss of the power of speech; thus a patient who received a slight wound of the neck did not speak again until the application of a battery by my colleague, Mr. H. B. Robinson. A patient was also for a short time an inmate of No. 1 General Hospital, Wynberg, who had become deaf and dumb as a result of the explosion of a shrapnel shell over his head. This patient also did not recover his powers until he returned to the mother-country. In many other cases of nerve concussion or contusion, the recovery of power and sensation, or the disappearance of neuralgia or contractures, was so sudden and rapid after prolonged continuance of the symptoms, as to suggest a very strong functional element in their origin. The influence of the general shock to the nervous system received by the patients had an important bearing on these phenomena, and their interest from a prognostic point of view was very great. INJURIES TO SPECIAL NERVES _Cranial nerves._--It will be convenient first to make a few remarks concerning the nerves of special sense. _Olfactory._--I observed temporary loss of smell on three occasions. In two instances this accompanied transverse wounds of the bones of the face in which the upper third of the nasal cavities was crossed; in the third a track passing obliquely downwards from the frontal region passed through the inner wall of the orbit, and crossed the nose at a lower level. In view of the small area of the olfactory distribution which was directly implicated, I was at first inclined to regard the loss of smell as dependent on the presence of dried blood on the surface of the mucous membrane, or on obstruction of the cavities from the same cause. Further observation, however, appeared to show that it was due to concussion of the branches of the olfactory nerve, since the loss of function persisted when the cavities were manifestly clear. In all these cases we were confronted with the same difficulty which was experienced both in lesions of sight and hearing, the determination as to whether the concussion was of the branches or of the olfactory bulb. When the symptom was the accompaniment of a fracture of the roof of the orbit, the possibility of concussion of the olfactory lobe was manifest. In all, again, it was difficult to say what part the accompanying concussion of the branches of the fifth nerve took in the production of the symptom. In all three cases mentioned the return of function was gradual, but apparently fairly complete at the end of three weeks. In one it was noted that at first the patient was conscious of an odour before he was able to discriminate its actual nature; later he could determine the latter readily. _Optic._--Some remarks concerning lesions of the optic nerve have already been made under the heading of wounds of the orbit. Concussion and contusion of the nerve both occurred, but I was unable to differentiate between the effects of these on the nerve itself, apart from the effects on the globe of the eye, which usually accompanied wounds of the orbit. In some cases the nerve was directly divided in orbital wounds, and either pressure on or division of the nerve in the intra-cranial portion of its course, or as it traversed the optic foramen, was not uncommon. _Auditory._--Loss of hearing was also not infrequent; thus it accompanied all three wounds of the mastoid process quoted under the heading of the seventh nerve, also two cases of fracture of the occipital bone near the ear quoted on p. 278. In all these instances it was impossible to attribute the deafness to lesion of the nerve alone, as the causative injury equally affected the internal ear, and in at least two the bullet implicated the tympanum as well in its course. The deafness was absolute in each case, and in none had any improvement occurred at the end of nine months. Deafness was a symptom in a certain number of the more severe cerebral injuries in which the course of the bullet was not so near to the internal ear: probably some of these were central in origin. I only once observed any interference with the sense of taste. _Remaining cranial nerves._--I have little to say regarding the _third_, _fourth_, and _sixth_ nerves. In the case of the third nerve, ptosis was occasionally seen in wounds of the skull involving the roof of the orbit, but the relative parts taken by injury to nerve and laceration or fixation of muscle respectively, were usually hard to determine. Again, the fourth and sixth nerves may have been damaged in some of the more extensive orbital wounds, especially those in which the globe suffered injury, but the signs under such circumstances were difficult to discriminate, and the injury was of slight practical importance, in view of the major injury to the globe itself. _Fifth nerve._--Concussion, contusion, or laceration of the different branches of the three divisions of the fifth nerve were common in wounds of the head, but most frequent in fractures of the upper or lower jaws. Localised anæsthesia was common from one or other of these causes, but for the most part transitory in the cases of contusion or concussion. I saw no case of entire loss of function in any one division, symptoms being mostly confined to certain branches, as the supra-orbital, the temporo-malar, the dental branches of the second division, the auriculo-temporal nerve, and the lingual, dental, and mental branches of the third division. I did not observe any cases in which modification of the special senses accompanied these injuries beyond those mentioned in the remarks already made on the subject of anosmia, and one case in which some modification of the sense of taste accompanied an injury to the floor of the mouth. It was a matter of surprise, considering the frequency with which subsequent neuritis was met with in the nerves generally, that trifacial neuralgia in some form was not more often met with. I never observed any serious case. Perhaps this is one of the fields in which a longer after-period may increase our knowledge. Lastly, I never observed motor paralysis in the case of the third division, although sensory symptoms in some of the branches were common, evident proof that injuries to the trunk were rare. _Seventh nerve._--Facial paralysis was most commonly observed in cases of wound of the mastoid process, apart from central cortical facial paralyses, of which several are quoted in the chapter on injuries of the head. All the wounds of the mastoid process were, in addition, accompanied by absolute deafness. I am sorry to be unable to give any details as to the electrical condition of the muscles in these cases, but I believe that in the great majority the paralysis was mainly the result of nerve concussion, since the perforations were clean in character and not obviously accompanied by comminution. Pressure from hæmorrhage into the Fallopian canal may, of course, have been present, and in some instances, particularly those in which the bullet traversed the tympanic cavity, spicules of bone may have caused laceration. In every case, however, all the branches were equally affected; the paralysis was absolute, and in none did any improvement occur while the cases were under my observation. The following are a few illustrative examples:-- (111) Boer wounded at Belmont. _Entry_, immediately above zygoma; the bullet passed through the temporal fossa, fractured the neck of the mandible, traversed the mastoid process, and emerged at the lower margin of the hairy scalp, 1 inch from the median line. Facial paralysis was complete, and there was no improvement at the end of ten weeks. (112) Wounded at Magersfontein. _Entry_, at the posterior border of the left mastoid process, 1/2 an inch above the tip; _exit_, through the right upper lip at the junction of the middle and outer thirds. There was considerable hæmorrhage from the left ear. The injury was followed by complete deafness, and facial paralysis, which showed no sign of improvement. There was complete anæsthesia over the area of distribution of the third division of the fifth nerve; this improved rapidly, and at the end of five weeks was hardly to be detected; neither at that time could any impairment of power on the part of the muscles of mastication be detected. No impairment of the sense of taste was noted. (113) _Entry_, above the anterior extremity of the zygoma, bullet retained. Primary hæmorrhage from ear. Complete facial paralysis and deafness. Anæsthesia over distribution of temporal branch of temporo-malar nerve, part of supra-orbital area, auriculo-temporal nerve, and small occipital cervical nerve. The muscles of mastication acted well. Ecchymosis below the right mastoid process. (114) Wounded at Paardeberg. 300 yards. _Entry_, at the posterior border of the right mastoid process, 3/4 of an inch above the tip; _exit_, the inner third of the left upper eyelid. (Eye destroyed.) Complete right facial paralysis; deaf, on right side cannot hear tick of watch either held close or in contact. Purulent otitis media. In this place I might mention two other cases of lesion of the seventh nerve secondary to wound of peripheral branches. In one a patient was struck by several fragments of lead from a bullet which broke up against a neighbouring stone. These for the most part lodged in the skin over the left orbicularis muscle, but one also lodged in the conjunctiva and was removed. Some ten days later the patient complained that he could not lift the upper lid. The levator palpebræ was normal, but spasm of the orbicularis held the eye firmly closed. The condition did not improve, and the patient was invalided home. He recovered later. In another patient a bullet entered above the right zygoma and traversed the orbits, without wounding the globes. At the time no want of power of the muscles of the face was noted, but a year later there was evident weakness of the whole of the muscles of the right side of the face, with loss of symmetry. In the former case the functional element was strong, but in both an ascending neuritis was probably present. _Tenth nerve._--The pneumogastric was implicated in many wounds of the neck. I never observed an uncomplicated case, but laryngeal paralysis was temporarily present in two of the cases of cervical aneurism in which the wound crossed above the level of origin of the recurrent laryngeal branch, while in two others the recurrent branch itself was in close contact with the wall of the aneurism (p. 135). In all such cases signs of concussion or contusion of the nerve would be expected, judging from the similar results observed in the brachial nerves when the neighbouring artery was implicated. The only obvious symptoms occurring, however, were laryngeal paralysis and acceleration of the pulse. As the latter symptom was often observed in the cases of arterio-venous communication, wherever situated, and as the sympathetic nerve also lay in close contiguity to the wound track, it was difficult to ascribe it with certainty solely to the vagus lesion. In the two cases of high vagus injury the laryngeal paralysis steadily improved, and at the end of six months was apparently well; in the two others it persisted at the end of three months and a year respectively. The nerve must have been very frequently damaged in wounds of the neck; it is possible that this injury may have been an important factor in the death of some of the patients with cervical wounds upon the field. _Eleventh nerve._--I append the only case of localised spinal accessory paralysis I observed. This was one of my earliest experiences, and when I examined the neck, in the Field hospital, I assumed from the completeness of the sterno-mastoid and trapezius paralysis that the nerve was severed. The patient, however, made such a rapid recovery that it became evident that the nerve had been contused only, and that the recovery of function was not due, as is so often the case, to vicarious compensation by the cervical supply to the muscles. (115) _Entry_, immediately to the right of the fourth cervical spinous process; _exit_, at the anterior border of the left sterno-mastoid opposite the angle of the mandible. The left shoulder was depressed, the head inclined to the injured side. There was evident spinal accessory paralysis, and marked hyperæsthesia of the whole left upper extremity, most severe in the circumflex area. The hyperæsthesia gradually disappeared in a few days, and was clearly due to concussion and possibly slight contusion of the cervical nerve roots. The spinal accessory paralysis improved, so that the patient returned to the front at the end of a month: when I saw him some four months later the shoulders were held quite symmetrically. The _twelfth nerve_ was occasionally damaged in wounds of the floor of the mouth. I saw no case of permanent paralysis. _Injury to the systemic nerves._ _Cervical plexus._--Evidence of injury to the superficial branches of the cervical plexus was not rare; thus I saw cases of small occipital anæsthesia, and great occipital neuralgia, but none of motor paralysis from injury to the deeper muscular branches. I take it that the smallness of the branches, and the multiple supply possessed by many of the muscles of the neck, would both take part in rendering certain evidence of the injury of an individual motor nerve rare. _Brachial plexus._--Injury to this plexus in the neck was common; the main peculiarity observed was the partial nature of the damage inflicted. Thus injury to a single nerve, or to a complex of two or more, was far more common than one implicating the whole plexus. Again, while complete paralysis might affect one set of nerves, another might simply exhibit signs of irritation in the form of hyperæsthesia or pain. The wounds producing these injuries varied much in direction; thus some crossed the neck transversely, some were obliquely transverse, while others took a more or less vertical course. These same remarks hold good in the case of the nerves of the arm. In the upper half, especially, complex injury was not rare, while in the lower third affection of individual nerves was more common. Another important difference must be mentioned in regard to the upper and lower segments of the course of the brachial nerves; they are not only more widely distributed below, but also more fixed in position, a fact antagonistic to the escape of the nerve by displacement and liable to expose it to more severe contusion. The latter point holds good in the forearm also; here, individual injuries often occurred. While at work in the Field hospital alone I gained the impression that the musculo-spiral nerve would not retain the unenviable character of being the most vulnerable nerve of the upper extremity, since the chances of each individual nerve seemed about equal, putting the question of the long course of the musculo-spiral nerve against the humerus out of question. This expectation was, however, not confirmed, since the musculo-spiral itself, if not primarily affected, was so often the seat of secondary mischief in fractures of the humerus. The posterior interosseous branch seemed to exhibit a similar vulnerability to slight injuries, to be referred to later under the external popliteal of the lower extremity. Again, in complex injuries of the brachial plexus, or nerve trunks, the musculo-spiral branch rarely escaped being a member, if not individually singled out. Of the _thoracic nerves_ I have little to say. They must have been often injured in the thoracic wounds, yet, as far as my experience went, intercostal neuralgia was uncommon, or at any rate not a special feature. One observation of interest, however, does exist; in the cases in which the ribs were fractured by bullets travelling across them within the thorax, pain was distinctly a prominent feature. This was no doubt referable to the facts that in such instances the intercostal nerves were especially liable to direct injury, and that this was often multiple. On one occasion a crop of herpetic vesicles developed along the course of a dorsal nerve in an injury implicating a single intercostal space posteriorly. _Lumbar plexus._--Although not quite so well arranged to escape bullet wounds as the thoracic nerves, the lumbar, by reason of their deep position and the comparatively wide area they cover, together with the rarity of wounds taking a sufficiently longitudinal direction to cross the course of more than one or two branches, were also comparatively rarely damaged. I never saw an uncomplicated case of anterior crural paralysis, and rarely cruralgia. I think this is to be explained in two ways: first, that the trunk course of the nerve is short; secondly, that it lies in the inguinal fossa. The second fact is of importance, since wounds in this region were in my experience responsible for a considerable percentage of the deaths on the field or shortly afterwards. Such deaths probably occurred from internal hæmorrhage from the iliac arteries, and it was in such cases that the anterior crural nerve stood in greatest danger of injury. I also never saw a case of localised obturator paralysis. On the other hand, anæsthesia or hyperæsthesia in the area of distribution of the lumbar nerves in the groin, the external cutaneous and the long saphenous in the thigh, were not uncommon. Hyperæsthesia developed in more than one case in which injury to the psoas had led to hæmorrhage into the muscle sheath. _Sacral plexus._--The sacral plexus is far more liable to extensive direct injury than either of the two preceding. Its cords are larger, gathered up into a much smaller space, and more liable to injury, from the fact that the slope in which they lie is more readily followed by a bullet track. Again, the cords rest for a considerable portion of their course on a bony bed, a particularly dangerous position in gunshot wounds, since the nerves are not only exposed to the danger of direct wound, or pressure from bony spicules, but also readily receive transmitted vibrations secondary to impact of the bullet with the bone. None the less I had few occasions to observe extensive injuries of the plexus. In one instance damage particularly affecting the lumbo-sacral cord occurred, but this was complicated by signs of irritation of the anterior crural and obturator nerves, as the result of retro-peritoneal hæmorrhage and injury to the psoas muscle. Two cases in which the sacro-coccygeal plexus suffered isolated injury on account of their characteristic nature as gunshot injuries will be shortly quoted: (116) _Sacro-coccygeal plexus._--_Entry_, at the junction of the middle and posterior thirds of the left iliac crest; the bullet passed obliquely downwards through the pelvis to lodge 3 inches below the right trochanter major. Incontinence of soft fæces persisted for five weeks, and retention of urine during three weeks. This patient subsequently died on the homeward voyage, but I am unable to say from what cause. (117) _Entry_, over third sacral vertebra; _exit_, 2 inches from the median line, and 1-1/2 inch above Poupart's ligament on the anterior abdominal wall. Incontinence, with involuntary passage of fæces, persisted during the first twenty-four hours, and for two days the urine had to be withdrawn with a catheter. No further signs of nerve injury were noted. The same explanation of the comparative rarity of injuries to the sacral plexus that has been already given in the case of the anterior crural nerve holds good--viz. that in a great many of the pelvic wounds involving the plexus early death followed from the severity of the concurrent injuries. Injuries to the great sciatic nerve outside the pelvis, or to one of its constituent elements, on the other hand, formed one of the most familiar of the nerve lesions. The wounds giving rise to these were of the most diverse character; some crossed the buttock in a vertical, transverse, or oblique direction; others travelled through the thigh in corresponding directions, while a third series involved both buttock and thigh. The size of the great sciatic nerve renders complete laceration by a bullet of small calibre a matter almost of impossibility; hence complete division may almost be left out of consideration in the case of this nerve. On the other hand, partial division, perforation, and severe contusion are each and all favoured by the same factor. With an extended thigh the nerve is in a state of comparatively slight tension, and this may be still lessened if the knee be flexed. This factor, together with the density of the sheath of the nerve, favours the possibility of displacement, and this occurrence is more likely in the lower segment than in the upper, which is comparatively fixed in position. Clinical experience appeared to illustrate the importance of these anatomical factors, as the worst cases of sciatic injury that I saw were in connection with wounds of the buttock or the junction of that segment of the trunk with the thigh. The most striking observation with regard to the injuries of the great sciatic nerve was the comparatively frequent escape of the popliteal element and the severe lesion of the peroneal. This was so pronounced as to amount to as high a proportion of peroneal symptoms as 90 per cent., and often when the whole nerve was implicated the popliteal signs were of the irritative, the peroneal of the paralytic type. When bullets crossed the popliteal space, given wounds of equal severity in corresponding degrees of contiguity to the respective nerves, the peroneal element always suffered in greater degree. Again, the peroneal nerve symptoms were more obstinate and prolonged, and instances of ascending neuritis were more common than in the case of any other nerve of the lower extremity, and the trophic wasting of muscles was more marked. The peroneal nerve, therefore, acquires the same unenviable degree of importance in the lower extremity enjoyed by the musculo-spiral in the upper. Here, again, we are confronted with the fact that the peroneal element of the great sciatic nerve is the more prone to idiopathic inflammations or toxic influences, and hence we can only assume it to possess a special vulnerability. The peroneal element is of course somewhat the more exposed, as lying posterior; but it seems unreasonable to assume that so large a proportion of the injuries can implicate the posterior segment of the nerve as to make the startling difference in the incidence of degeneration explicable. In this relation we may bear in mind that the muscles supplied by this nerve suffer most in the degeneration subsequent to anterior polio-myelitis, and again that in cerebral hemiplegia or spinal-cord injuries they are the last to recover. Unfortunately no explanation of these remarkable facts, so forcibly impressed by the large series of cases with peroneal symptoms seen in a short time, is forthcoming. I may dismiss the other branches of the sacral plexus in a few words. The small sciatic was occasionally injured in its course in the buttock, and the small saphenous in the leg. When either element of the latter was injured, it was surprising how sharply the imperfections in the anæsthesia corresponded with the composite character of the nerve. CASES OF NERVE INJURY The following cases are added mainly to give some idea of the comparative frequency with which the individual nerves were injured, and also to exemplify the more common forms of complex injury met with. Circumstances, unfortunately, did not always allow of extended observation at the time, and I have not been very fortunate in my attempts to obtain subsequent information on this series since my return. A certain amount of prognostic information is, however, furnished by some of the records, and I am very much indebted to my colleague, Dr. Turney, for help in this matter. (118) _Brachial plexus._--_Entry_, 2 inches above the clavicle at the anterior margin of the trapezius; _exit_, first intercostal space, 1 inch from the sternal margin. Heavy dull pain developed at once, extending down the upper extremity. A fortnight later this pain still persisted; there was lowered sensation in the ulnar area with formication, also lowered sensation in the internal cutaneous area of distribution; sensation in the lesser internal cutaneous area was normal. The patient went home with the nerve symptoms well at the end of a month. (119) _Brachial plexus injury._--Wounded at Magersfontein. _Entry_, at the anterior border of the sterno-mastoid opposite the pomum Adami; _exit_, through the ninth rib below and 1/2 an inch external to the scapular angle. Emphysema and considerable blood extravasation developed in the posterior triangle of the neck, also loss of power in the musculo-spiral distribution, but no anæsthesia. At the end of the first fortnight there was evident wasting of the muscles, but some power was returning in the triceps. At the end of a month the man left for England, with fair power in the triceps, but well-marked wrist-drop. A year later the wrist-drop still persisted. (120) _Plexus injury._--Wound of _entry_, over pomum Adami; _exit_, below scapular spine, about centre. Complete median and musculo-spiral paralysis. (121) _Median, musculo-cutaneous, and musculo-spiral nerves._--The wound traversed the axilla from just beneath the anterior fold; three weeks later a firm mass in the axilla corresponded to the wound track. Hyperæsthesia developed in the area of median distribution, with deep pain in the muscles. There was rigidity of the biceps cubiti and slight wasting in the radial extensors. The patient improved slowly, and eventually was discharged and passed out of sight. (122) _Brachial nerves._--Wounded at Paardeberg. Range 500 yards. _Entry_, at the front of the arm, 2 inches below the junction of the anterior axillary fold; _exit_, a little lower, at the back of the arm, in the line of junction of the posterior axillary fold. Considerable shock attended the primary injury; when reaction had taken place, complete motor and sensory paralysis was noted of the whole upper extremity, with the exception of some power of movement of the posterior interosseous group of muscles. Three weeks later the patient could extend the wrist, but sensation was imperfect in the arm, and completely absent in the forearm and hand. The track was now hard and palpable, but there was no hyperæsthesia in any area; when the track was manipulated slight formication in the hand was experienced. The biceps and triceps were equally paralysed. There was no wasting in any of the muscles. (123) _Brachial nerves._--Wounded at Modder River. _Entry_, through the anterior axillary fold at its junction with the arm; _exit_, on the posterior wall of the thorax, 1/2 an inch from the median line at a level with the angle of the scapula. Complete musculo-spiral paralysis; hæmothorax. Three weeks later, radial sensation returned; but the triceps was very weak, and wrist-drop was complete. There was some wasting of the muscles supplied by the median and ulnar nerves, and complete obliteration of the radial pulse. A year later the musculo-spiral paralysis still persisted. (124) _Musculo-spiral and median._--Wounded at Magersfontein. _Entry_, 3 inches below the anterior axillary fold, on the inner aspect of the arm; track passed obliquely downwards behind the humerus to a point on the outer aspect of the arm 1-1/2 inch below the level of the entry. The humerus escaped injury. Musculo-spiral paralysis was complete; hyperæsthesia in the distribution of the median followed some days later. One month subsequently radial sensation had returned, and a feeling of numbness had taken the place of the median hyperæsthesia. The triceps and marginal muscles were much wasted, and only interosseous extension was possible in the fingers. (125) _Brachial nerves._--Wounded at Magersfontein. _Entry_ and _exit_, in the upper third of the arm internal to the humerus. Complete median paralysis, anæsthesia in the ulnar area, and in the radial supply to the dorsum of the middle and ring fingers. Could flex, extend, and adduct and abduct the wrist; some power of flexion in index finger, in others none. The flexion of the wrist was dependent on the ulnar supply to the muscles of the forearm. No wasting of the interossei, skin normal except for a large trophic blister on the dorsum of the hand. Little improvement had taken place in this patient at the end of a year. (126) _Brachial nerves._--Wounded at Magersfontein. The wound traversed the lower part of the upper third of the arm, fracturing the humerus. Immediate complete loss of power in the arm was experienced, together with loss of all sensation. Three weeks later the humerus was united; the fracture was evidently the result of passing contact, and not of direct impact. The paralysis was still complete in the distribution of the median, ulnar, and musculo-spiral nerves. There was considerable wasting of the hand and forearm, and a good deal of thickening in the lower third of the arm. Four months after the original injury, the nerves were explored by Mr. Eve, who kindly gives me the following information. All the nerves and vessels of the arm were united into one firm bundle by cicatricial tissue. When dissected clear, the median nerve was found to be thickened and enlarged for about 1-1/2 inch of its length; the ulnar was not completely freed, but was found to be continuous and indurated; the musculo-spiral was also intact, but at its entrance into the humeral groove a mass of callus was felt. A sclerosed and thickened portion of the median nerve 3-1/2 inches in length was resected, also 1 inch of sclerosed ulnar nerve, and both were sutured. The musculo-spiral nerve was left for future exploration. A small traumatic aneurism was found on the brachial artery, and the vessel was ligatured above it. Ten months later no improvement in the median or ulnar nerves. Electrical reaction present in musculo-spiral group of muscles. (127) _Musculo-spiral._--Transverse wound through arm posterior to humerus. Slight suppuration. Triceps weakened only, complete paralysis of radial extensors and posterior interosseous group. Radial sensation lowered only. (128) _Musculo-spiral._--_Entry_, 2 inches above and 1/2 an inch behind the external humeral condyle; _exit_, at the inner edge of the biceps, 1/2 an inch lower in the arm than the entry. It is doubtful whether the paralysis was noted at first, but a few days later complete posterior interosseous paralysis and lowered radial sensation were remarked. No change except a deepening of the anæsthesia, and the development of formication on manipulation of the wound occurred, and at the end of three weeks the nerve was exposed (Mr. Watson), and it was found that a notch had been cut in its outer border, which had opened out into a V shape. The margins of this notch were refreshed and the gap closed. Ten days later radial sensation was fairly good, but the motor symptoms remained unchanged. Nine months later steady but very slow improvement was reported. (129) _Ulnar and musculo-cutaneous nerves._--_Entry_, back of forearm; the bullet passed between the bones and was retained at the posterior aspect of the arm. Three weeks later the hand was glossy and stiff, the fingers extended and adducted, the thumb was held stiffly in the palm with no power of extension. The forearm was held semiprone, and the elbow flexed by a rigid biceps. Six months later the same position was maintained, but the contracture disappeared under an anæsthetic. (130) _Median and posterior interosseous._--_Entry_, over the external margin of the radius at the centre of the forearm; _exit_, at the inner margin of the olecranon 1-1/2 inch below the tip. Lowered cutaneous sensation in median distribution, and loss of median flexion of wrist and fingers. Complete wrist-drop. The triceps supinator longus and extensor carpi radialis longior were perfect. Twelve days later the wrist could be raised into a direct line with forearm, but there was no change in the median symptoms. A week after this the anæsthetic median area became hyperæsthetic both as to skin and on deep pressure over the muscles. (131) _Sacral plexus. Great sciatic nerve._--Wounded at Modder River. _Entry_, in left loin; _exit_, at lower margin of buttock. The wound was followed immediately by complete peroneal paralysis, both motor and sensory. Fourteen days later hyperæsthesia developed in the area of distribution of the internal popliteal nerve, the superficial pain being greatest in the sole; the muscles of the calf were also very tender on manipulation. The pain increased, and at the end of twenty-four days the patient's sufferings were so great that Mr. Thornton cut down upon and exposed the nerve. It was found embedded in firm cicatricial tissue close to the sciatic notch; this compressed the nerve to such a degree that a waist was apparent upon it. The nerve was freed and resumed its normal outline. For a few days the patient was much relieved, but the neuralgia then returned in greater intensity than ever. Morphia was injected hypodermically, and other hypnotics employed, but with little effect, the patient developing the hysterical condition so common in the subjects of severe sciatica. Some five weeks later a sudden improvement took place, the morphia was decreased, and the patient became sufficiently well to return to England, but there was still deep tenderness in the calf, and well-marked hyperæsthesia of the sole. A year later the patient had been discharged from the Service, but was earning his living in a shop. He walked fairly well, but still with foot-drop, and complained of tenderness in the sole. I am indebted to Dr. Turney for the following report on the condition of the muscles. Calf muscles practically normal. In the anterior tibial and peroneal groups the faradic irritability is much diminished, that in the peroneus longus being the lowest of all. Contraction can be induced in the extensor longus hallucis, extensor longus digitorum, and peroneus brevis; but reaction is doubtful in the case of the tibialis anticus and peroneus longus. With the galvanic current contraction is sluggish, and the irritability diminished. No serious changes are present except in the peroneus longus. ACC > KCC at 10 M. A. (132) _Great sciatic._--_Entry_, at outer aspect of the thigh, just above the centre; _exit_, at the junction of the inner and posterior aspects of thigh, about 2 inches lower. The wound was produced by a ricochet bullet, and beyond the perforation of the sciatic nerve the femur was fractured obliquely (see plate XVI.). Hyperæsthesia of the sole was noted early, and when I saw the patient three months later, there was wasting of the muscles of the leg, and foot-drop, although he walked with a stick. These symptoms persisted, and on his return to England an exploration was made by Sir Thomas Smith, and the two fragments of mantle seen in the skiagram were removed from the substance of the sciatic nerve. Eight months after the injury, the patient still walked with foot-drop; there was modified sensation in the musculo-cutaneous area, and a feeling as if the bones of the foot were uncovered when he walked. The circumference of the affected leg was more than 1 inch less than that of the sound one. Steady but slow improvement was taking place. (133) _Great sciatic_.--In a third patient with a buttock track, the symptoms were identical with those observed in case 131. In this an exploration showed that the nerve had been perforated. Although the symptoms were never so severe as in No. 131, yet recovery was very much slower and less complete, the muscular weakness remained more marked, and the skin exhibited more evidence of trophic lesion. Some contracture of the knee and rigid foot-drop took place, and at the end of twelve months the patient walked poorly with a stick. Improvement is, however, continuing. (134) _Great sciatic_.--Wounded at Ladysmith. _Entry_, immediately below left buttock fold; _exit_, at anterior aspect of thigh, 3-1/2 inches below Poupart's ligament. The left leg was paralysed, and patient was sent down to the Base, where he remained two months. The wound closed by primary union, the paralysis improved, and the man rejoined his regiment. After he had been in camp four days, his leg gave way, and he returned to hospital, where he contracted enteric fever. Later, he was sent home, and eight months after the reception of the injury his condition was as follows: Left lower limb somewhat wasted, a diminution of 1 inch in the circumference of the leg and 1/2 an inch in the thigh being found. The patient walks with foot-drop, and the flexor muscles of the knee are weak. On examination the peroneal muscles reacted but sluggishly to faradic irritation. There is complete anæsthesia of the foot to above the ankle, and up to the knee tactile sensation and appreciation of pain were dulled. The left plantar reflex was absent, the right slight, the left patellar reflex was abnormally brisk. There was neither ankle nor patellar clonus, and the other reflexes were present and normal. The gait was spastic, and the patient was more troubled by a contraction of the calf muscles, which prevented his putting the heel to the ground, than by the foot-drop. Beyond these local phenomena there was marked tremor of the upper extremities on any exertion, and slight lateral nystagmus. The patient was not sure that this had not been present ever since he recovered from the enteric fever, but it was sufficiently marked to give rise to the suspicion of the development of disseminated sclerosis. The patient was a hard-headed, sensible man. He remained in the hospital under the care of Dr. Turney, to whom I am indebted for notes of the case, forty-six days. During this period he was treated by faradic electricity, and, with some checks, notably the development of passive effusion into the left knee-joint, and a fugitive attack of redness over the dorsum of the foot, both suggesting trophic changes, steadily improved. The anæsthesia became limited to the outer half of the leg, at the end of one month was limited to the dorsum of the foot only, and at the end of six weeks entirely disappeared. Meanwhile the tendency to drawing up of the heel by the calf muscles became less, and the gait improved. The man left the hospital at the end of two months, very satisfied with his condition, although the tremor of the hands was still present in a lessened degree. (135) _External popliteal._--Wounded at Magersfontein, 250-300 yards. _Entry_, at the outer side of the thigh, 5 inches above the lower extremity of the external condyle; _exit_, at the inner margin of the adductors, at a level 4 inches higher in the thigh. The track crossed behind the femur. Complete peroneal motor paralysis and anæsthesia, except in the hinder part of the region supplied by the mixed external saphenous. Slight hyperæsthesia of the sole. Improving at the end of three weeks, but paralysis still nearly complete. (136) _External popliteal._--Wounded at Magersfontein. _Entry_, 5 inches below the highest part of the right iliac crest, on outer aspect of hip; _exit_, at the posterior margin of the gracilis, 2 inches from the perineum. Complete peroneal paralysis followed, which rapidly improved, and on the twenty-second day was nearly well. (137) _Internal popliteal. Secondary anæsthesia_.--_Shell_ wounds of the right popliteal space. Wounded at Belmont. Anæsthesia of the outer side of the calf, the leg and sole of foot. No motor paralysis. As cicatrisation progressed, the anæsthesia became more marked and was complete over the whole of the external saphenous area. (138) _Internal popliteal._--Wounded at Paardeberg. 400-500 yards. _Entry_, about the centre of the outer half of the patella; _exit_, at the centre of the calf, about 2 inches from the popliteal crease. Five days after the injury severe burning pain developed in the sole. A fortnight later the pain was much less severe, but varied in degree with the heat of the weather, being worse when cool. At this date, however, rubbing became comforting. (139) _External popliteal._---Wounded at Magersfontein. _Entry_, 1 inch above the upper end of the internal margin of the patella; _exit_, at the margin of leg, just below the outer tuberosity of the tibia. Complete peroneal paralysis followed the injury. A month later the nerve was bared and found slightly thickened. An improvement in cutaneous sensation followed quickly, and a much slower improvement in the motor power commenced. (140) _External popliteal nerve._--Wounded at Beacon Hill. A _bayonet_ entered over upper quarter of fibula, and passed between the bones of leg into the calf. An aneurismal varix of the calf vessels developed, also incomplete peroneal paralysis. The scar was raised from the nerve (Major Simpson, R.A.M.C.) six weeks later, and at the end of a fortnight the power and sensation were both much improved and the patient returned to England. (141) _External popliteal._--Wounded at Modder River. _Entry_, 1/2 an inch above the internal border of the patella; _exit_, 1-1/2 inch from the head of the fibula and over that bone. The wound was followed by peroneal paralysis. Six weeks later sensation was still diminished in the anterior tibial and musculo-cutaneous nerve areas, and marked foot-drop, little improved, persisted. The patient came to England, and at the end of twelve months is reported as very little improved. (142) _Anterior tibial._--_Entry_, 1 inch in front and below the external malleolus; _exit_, at the centre of the sole, just anterior to the bases of the metatarsal bones. Wasting and paralysis of extensor brevis digitorum. (143) _Small sciatic and small saphenous._--Wounded at Magersfontein. 200 yards. Two wounds: (i) _Entry_, below the centre of the twelfth rib on the left side; _exit_, immediately to the left of the buttock furrow at upper part, (ii) _Entry_, in the right loin, midway between the last rib and iliac crest; _exit_, just within the centre of the left buttock; the two wounds crossed diagonally. Hyperæsthesia in area of distribution of small saphenous and small sciatic nerves, which rapidly improved. (144) _Lumbar plexus._--Boer, wounded at Magersfontein. _Entry_, eleventh interspace, posterior axillary line; _exit_, tenth interspace, right mid-axillary line. Impaired sensation in area of distribution of external cutaneous and crural branch of genito-crural nerves. At the end of a fortnight anæsthesia was less apparent, but a feeling of numbness persisted, which soon disappeared. _Prognosis and treatment._--In considering the prognosis in cases of nerve injury, several of the points already raised as to the nature of the lesion are of importance. Short of actual section, it may be broadly stated that no lesion is too serious to render ultimate recovery impossible. In cases in which the injury has been produced by a bullet fired at a short range, or in which contact with the nerve has been close, the return of functional activity is very slow. In such instances the condition probably resembles that in which a divided nerve has been sutured, with the additional disadvantage that a considerable portion of the nerve, both above and below the point actually struck, has been destroyed as far as the conduction of nervous impulses is concerned. This may reasonably be concluded in the light of the evidence offered by the injuries of the spinal cord, in which several segments usually suffered if the velocity of the bullet was great, and also if the fact is remembered that, when thickening takes place, a considerable length of the nerve is usually implicated. Recovery is notably slow in the case of certain nerves, _e.g._ musculo-spiral and peroneal, even when the injury has not been of extreme severity. Again, these same nerves are apparently more seriously affected by moderate degrees of damage than are others. As favourable prognostic elements we may bear in mind: low velocity on the part of the travelling bullet, and with this a lesser degree of contiguity of the track to the nerve. The early return of sensation is a favourable sign, and in this relation the development of hyperæsthesia, whether preceded by anæsthesia or no, points to the maintenance of continuity of, and a moderate degree of damage to, the nerve. The early return of sensation, even if modified in acuteness, was always a very hopeful sign; also the production of formication in the area of distribution of the nerve on manipulation of the injured spot. As in the case of nerve injuries of every nature, the disposition and temperament of the patient exerted considerable influence on the course of the cases. Complete section of the nerves in these bullet wounds only obtained special importance in two ways: first, in that a considerable portion of the trunk might be shot away in oblique tracks, and, secondly, in that very severe contusion might affect the nerve for a considerable distance beyond the point actually implicated. In point of fact, complete section when treated by suture was often more rapidly recovered from than an injury in which only a portion of the width of a trunk was divided. This was no doubt to be explained on the theory that the contiguous portion of the nerve suffered less when tension and resistance were lessened by complete severance of the cord. _The treatment_ of slight nerve contusion was simple; rest alone was necessary, and in the course of hours or days paralysis was recovered from. The symptoms were most troublesome in patients of a neurotic temperament, or those who had suffered from severe systemic shock. In severe concussions and contusions the first care had to be devoted to the discrimination of the lesion from that of division. A period of rest then needed to be followed by one of massage and movement, to maintain the nutrition of the muscles. In a considerable portion of the cases a stage of neuritis had to be expected. In all cases, either of severe concussion, contusion, or complete section, accompanied by the fracture of a bone, especial care was necessary that the bandaging and fixation of the limb were not sufficiently tight to add the dangers of muscular ischæmia to those of the nerve injury already present. Neuritis, whether dependent on local injury, implication in the scar, pressure from callus, or of the ascending variety, needed the same treatment: rest, preservation of the limb from cold or damp, and the local application of anodynes, as belladonna, or hot laudanum fomentations. In some cases a general anodyne, as morphia, was preferable; then always to be used with caution, as the patients soon craved inordinately for it, and were unwilling to give it up. Later, local blisters in the line of the nerve trunk, careful massage and exercise when muscular and cutaneous tenderness had subsided, the application of the continuous current to the nerves, and perhaps faradisation of the muscles, were all useful. Splints were often temporarily required to resist contracture, or the assumption of false positions; in either case they needed to be frequently removed, and movement &c. made, in order to avoid any chance of troublesome stiffness. _Operative treatment._--Early interference was only warranted by positive knowledge that some source of irritation or pressure could be removed; thus a bone spicule, or a bullet, or part of one, particularly portions of mantles. In case of contusion the expiration of three months is the earliest date at which any operation should be taken into consideration, and interference is only then advisable if there is good prospect of freeing the nerve from compressing adhesions. The two strongest indications for operation are (1) signs pointing to the secondary implication of the nerve in a cicatrix, especially when these are of such a nature as to indicate local tension, fixation, or pressure; (2) the possibility of the irritation being the result of the presence of some foreign body, such as a bone spicule, or portions of a bullet mantle; in such cases the X rays will often give useful help. With regard to the early exploration of cases of traumatic neuralgia, it may be pointed out that when this was undertaken the results were as a rule very temporary. In many cases in which the measure was resorted to, either no macroscopic evidence of injury to the nerve was discovered, or a bulbous thickening was met with of such extent as to make excision inadvisable, even if it were considered otherwise the most suitable treatment. Even when complete section of the nerve was assured by the absence of any power of reaction to stimulation by electricity from above on the part of the muscles, operation was better not undertaken until cicatrisation had reached a certain stage. If done earlier than at the end of three weeks, the sutured spot became implicated in a hard cicatrix, and any advantage to be obtained by early interference was lost. When partial division of a trunk was determined, the same date was the most favourable one for exploration, the gap in the nerve being freshened and closed by suture. There is little doubt, however, that in some cases such injuries were recovered from spontaneously. In view of the uniformly bad results observed in the case of the seventh nerve, I am inclined to think that the above rules might be tentatively relaxed, and the nerve primarily explored by an operation resembling that for mastoid suppuration. It is of course doubtful whether the trouble does not generally result from the vibratory concussion alone; but as this is not certain, and the operation would only have to be performed on patients already permanently deaf, it might be worth while at any rate opening the Fallopian canal with the object of relieving tension. It is not probable that in any of the cases quoted much splintering of the bone had occurred, as the wounds appeared to be of the nature of pure perforations. CHAPTER X INJURIES TO THE CHEST In regard to Prognosis wounds of the chest furnished the most hopeful class of the whole series of trunk or visceral injuries. Cases of wound of the heart and great vessels afforded the only exceptions to an almost universally favourable course, both as regards life and the non-occurrence of serious after-effects. This was mainly explicable on two grounds: first, the sharply localised character of the lesion produced by the bullet of small calibre; and, secondly, the fact that the lung, the most frequently injured organ, is not materially affected by the grade of velocity with which the bullet strikes. In point of fact, wounds of this organ probably afford an instance in which high grades of velocity are distinctly favourable to the nature of the injury, and this is possibly true in the case of wounds of the chest-wall also. The significance of the calibre of the bullet in wounds of the chest is evident. The late Mr. Archibald Forbes, in one of his letters from the seat of the Franco-German war, remarked that in crossing a battlefield it was easy to recognise the patients who had suffered a wound of the lung from the fact that the whistle of the air entering and leaving the chest was plainly audible. This was, indeed, not uncommonly the case in wounds produced by the older bullets of large calibre, but with the employment of the smaller projectile it has become an experience of the past. Some evidence as to the comparative severity of wounds produced by the larger forms of bullet was, moreover, afforded by the present campaign, since Martini-Henry wounds were occasionally met with. Of some instances observed by myself, in one, external hæmorrhage was a prominent symptom; in another, a piece of lung was prolapsed from a wound in the back, and twice I observed pneumothorax, an uncommon sequela to wounds from bullets of small calibre. It may be remarked, however, that all these more serious injuries were recovered from, also that when we consider that the patients were comparatively young and healthy subjects, the favourable prognosis was what might have reasonably been expected. When, as occasionally happened, a patient of more mature years, with enlarged facial capillaries, received a wound of the lung, the course was in no way so favourable as that witnessed in the case of the younger men. In support of this opinion I may add that wounds from shrapnel and fragments of shell also did remarkably well, although they sometimes gave rise to more troublesome symptoms than did wounds produced by bullets of the Mauser type. Again, these injuries as a whole were of nothing like so serious a nature as the lacerations of the lung produced by fractured ribs, which we commonly have to treat in civil practice, and are not accustomed to regard as especially dangerous. It is also a striking fact that the most common and troublesome complication of wounds of the chest, hæmothorax, was usually the result of the wound of the chest-wall and not of the lung. I preface these remarks to the detailed account of the thoracic injuries, because I think the favourable course usually taken by patients with wounds of the lung has been accorded somewhat greater prominence than the circumstances warranted. _Non-penetrating wounds of the chest-wall._--Surface wounds were not very common, and were chiefly of interest in so far as they illustrated the very superficial course that may be occasionally taken by a bullet without breach of the integument, and as sometimes affording opportunity for the exercise of diagnostic skill when the track traversed the axilla. The most common situation for tracks taking a long course on the surface of the thoracic skeleton was the back. Such wounds were usually received while the patients were prone on the ground; thus I might instance a case in which the bullet entered the posterior aspect of the shoulder 3 inches above the spine of the scapula, passed downwards, pierced that process, and emerged 2 inches below the inferior angle of the bone. Wounds of a similar nature coursing in transverse and oblique directions, and not implicating bone, were also seen. Those implicating the vertebræ have been already dealt with. The scapular region was also a favourite one for the lodgment of retained bullets, some resting in the supra- and infra-spinatus muscles, others lying beneath the bone itself. On the anterior aspect of the chest, bullets coming from the front sometimes traversed and fractured the clavicle, and then took a short course downwards, emerging over the ribs or sternum. Figure 81 represents a particularly long track in this region. In other cases the precordial region was crossed, but I never witnessed any serious effect on the heart's action in any such injury at the time the patients came under my notice. Wounds received with the arm outstretched and traversing the axilla sometimes gave considerable trouble in excluding with certainty a perforation of the thoracic cavity. Thus a bullet entered below the centre of the right clavicle and emerged 2-1/2 inches below, above the angle of the scapula, at its axillary margin. The arm was outstretched at the moment of the reception of the injury; but when the wound was viewed with the limb placed alongside the trunk, it seemed almost impossible that the chest cavity could have escaped. In some cases of this kind the difficulty was at once cleared up by noting evidence of injury to the axillary nerves. A word will suffice as to the treatment of these wounds. The only special indication was to keep the scapula at rest for a sufficient period. I have dealt with the anatomy of them at such length only because in their extreme form they are so highly characteristic of the nature of the injuries which may be produced by bullets of small calibre. _Penetrating wounds of the chest._--Tracks crossing the thoracic cavity in every direction were common. When the erect attitude was maintained, frontal and sagittal wounds, pure or oblique, were received; when the prone position was assumed, longitudinal tracks, either purely or obliquely vertical, were the rule. Experience of wounds of the latter class was extensive in the present campaign, from the fact that so many of the advances were made in prone or crawling attitudes. The vertical and transverse tracks each possessed the special characteristic of frequently implicating both the thoracic and abdominal cavities, but the vertical were often prolonged into the neck, or even downwards through the pelvis. The vertical wounds in addition sometimes exhibited one very important feature, the fracture of several ribs from within, often at a very considerable distance from the aperture of either entry or exit. [Illustration: FIG. 81.--Superficial Track in anterior Wall of Trunk] _Characters of the apertures of entry and exit._--As has already been mentioned, the chest-wall was one of the situations in which the aperture of entry was often large, and the oval form due to obliquity of impact on the part of the bullet was particularly well marked. The exit wounds were often smaller than those of entry, especially if the bullet emerged by an intercostal space; even when the ribs were comminuted, the fragments were, as a rule, too small to occasion more than a slightly enlarged and irregular aperture. Taken as a class, however, and putting aside explosive exit wounds, wounds of the chest afforded more numerous examples of irregular outline and variation in size than were met with in any other region of the body. When the tracks penetrated the broad upper intercostal spaces, an interesting feature, due to the tense and rigid nature of the muscles closing the intervals, and their large admixture of fibrous tissue, was sometimes noticed. The bullet, especially if passing obliquely, was apt to cut a slit in the muscles far exceeding in size the opening in the overlying integument, with the result of leaving a palpable subcutaneous defect. Under these circumstances the yielding spot was often noticed to rise and fall with the movements of respiration, external palpation met with an absence of normal resistance, and there was impulse on coughing. _Fractures of the ribs._--These injuries were produced in either transverse or longitudinal coursing tracks, their special feature being a sharp localisation of the lesion of the bone. In tracks crossing the chest transversely the injury to the ribs might consist in notching, perforation, or complete solution of continuity, sometimes with fine comminution. In the incomplete injuries some importance attached to the localisation of the lesion to the upper or lower border of the rib, in so far as the intercostal artery was concerned. Comminution at the wound of entry was, as a rule, not so extensive as at the aperture of exit, and in any case was less apparent, since the fragments were driven inward. The wider comminution at the exit aperture depends on the lesser degree of support afforded by the thoracic coverings to the convex outer surface of the rib, and on the fact that the velocity of the bullet has been lowered by its passage through the opposite rib and the chest cavity. The splinters of comminuted ribs are small, and wide-reaching fissures rare. These characters depend on the elastic nature of the resistance offered by the curved rib to the passage of the bullet, which is calculated to preserve the bone from the full force of impact, except at the point actually impinged upon. Fractures of the ribs, produced from within by bullets taking a longitudinal course through the thorax, were still more special in character. They were also more important, as giving rise to troublesome symptoms. In these, again, the degree of injury to the bones varied considerably. In some cases the bones were merely grooved internally, without any external deformity; in other cases a sort of green-stick fracture was produced, accompanied by the projection of a tender salient angle externally; in others complete solution of continuity was effected. Another feature of importance was the occasional implication of several ribs. In this case the symptoms accompanying the injury were very much more like those observed in the corresponding injuries resulting from indirect violence seen in civil practice. Injuries to the _costal cartilages_ closely resembled those to the ribs. Perforation, bending from injury to the inner aspect, and comminution were observed. The latter condition differed from the similar one seen in the case of the ribs only in so far as the tougher consistence of the cartilage did not lend itself to such free comminution, and the splinters remained in great part attached. The nature of the fractures, in fact, somewhat resembled that seen on breaking a piece of cane. I saw no fracture of the _sternum_ except of the nature of a pure perforation; these were not uncommon in the hospitals, either in the upper or the extreme lower portions of the bone. Fractures in other portions were no doubt usually associated with fatal injuries to the heart. The openings were usually so small as to be difficult of palpation, and I never had the opportunity of examining one _post mortem_. Perforations of the body of the _scapula_ were common, but they were of little importance in symptoms or prognosis. _Symptoms of fracture of the ribs._--Fractures accompanying transverse wounds of the chest were characterised by the insignificance of the symptoms produced. Every common sign of fracture of the rib was in fact absent. Neither pain, stitch on inspiration, nor crepitus, either audible or palpable, was, as a rule, present. This absence of signs was accounted for by the nature of the lesion: thus in perforations or notchings there was no loss of continuity, while in the freely comminuted fractures the loss of continuity was so absolute as to allow no possibility of the main fragments rubbing together. Again, part of the symptoms attending these injuries, as seen in civil practice, depends upon contusion and laceration of the surrounding structures--a condition precluded by the localised nature of the application of the violence by a bullet of small calibre. In order to establish a diagnosis, therefore, we were in many cases reduced to palpation, and occasionally to direct examination of the wound. Fractures accompanying longitudinal tracks formed a class rather apart in the matter of symptoms. In these mere groovings might also be accompanied by no signs, or at the most by slight local pain and tenderness. When, however, the grooving was sufficiently deep to be accompanied by deformity, or a complete solution of continuity was effected, the signs were often severe. The tender salient angle, or, in the absence of this, a highly tender localised spot, often pointed to the less severe injuries, and when the fractures were complete or multiple, pain was a very prominent symptom, both constant and in the form of inspiratory stitch. The severity of the pain was probably to be in part ascribed to implication of the intercostal nerves, which in these injuries was direct and often multiple. Again, severe contusion or actual laceration of the nerves, with resulting anæsthesia, was less common than when the bullet directly implicated the nerves in transverse wounds. Free comminution and absolute solution of continuity were also less common than in the fractures accompanying transverse wounds; hence pain from rubbing of the fragments on inspiratory movement or palpation was more common, and crepitus, either on auscultation or palpation, was more often met with. Patients with this class of fracture often suffered greatly from painful dyspnoea, and were unable to assume the supine position. _External hæmorrhage_ of severity was rare from these thoracic wounds; in many cases it did not amount to more than local staining of the shirt; altogether I saw only one or two cases where any serious bleeding occurred. Internal hæmorrhage into the pleura, in consequence of the position of the intercostal arteries, was common, and often abundant; this will be treated of under the heading of hæmothorax. _Treatment of fractured ribs._--Transverse wounds of the thorax, with no symptoms of fractured ribs, needed to be dealt with as wounds of the soft parts alone. In multiple fractures accompanying longitudinal tracks, bandaging or strapping for the purpose of fixation was necessary to relieve pain. A few fragments of bone sometimes needed primary removal, and occasionally small sequestra were removed at a later date; but necrosis was rare, unless some complication led to the development of a fistula. Retained bullets were occasionally met with in the chest wall. In such cases the last remaining energy of the bullet often seemed to have been spent in diving under the margin of a rib and turning longitudinally up or down. Removal was sometimes necessary, either from the prominence produced, the presence of pain, or the continuance of suppuration. Some of the specimens removed offered interesting evidence of the capacity of the ribs to withstand considerable violence from a bullet. These were slightly bent, and marked by a half-spiral groove. I saw such bullets removed from the thoracic and the abdominal wall, and the evidence seemed rather against the groove having been produced prior to their entrance into the body. [Illustration: FIG. 82.--Spirally grooved Mauser Bullet] _Wounds of the diaphragm._--Perforations of the diaphragm were very frequent, and as a rule of small significance. When, however, the course taken by the bullet was parallel with that of the slope of the diaphragm, a more or less extensive slit was the result. I saw such a wound still gaping, and 2 inches in length, in the body of a patient who died three weeks after the infliction of a fatal abdominal injury. In several other obliquely transverse thoracic wounds there was reason to assume the existence of similar slits. Certain signs were more or less constant under these circumstances. These consisted in shallow respiration, often accompanied by a groan or the slightest degree of hiccough on inspiration, and considerable increase in respiratory frequency. In one patient the respirations were at first 48, only dropping to 36 some seventy hours after the reception of the injury. In some of the cases in which the abdominal cavity was implicated, wound to the diaphragm seemed a more likely explanation of early, frequent, and painful vomiting than did visceral injury. The possibility of the later development of diaphragmatic herniæ in some of these patients will have to be borne in mind in the future. _Visceral injuries._--The frequent escape of the thoracic viscera from injury, putting aside the lungs which fill so great a part of the cavity, was very remarkable. I never saw a case in which I could assume injury to any of the posterior mediastinal viscera, although such may have occurred on the field of battle. An injury to the oesophagus, for instance, would almost of necessity be accompanied by wound of either one of the large vessels, even the thoracic aorta, or the spinal column. I was somewhat surprised, however, to learn on enquiry from surgeons who had seen a large number of the dead and dying on the field, that thoracic wounds, putting aside those that directly implicated the heart, were responsible for but a small proportion of the fatalities. The escape of the posterior mediastinal viscera, the great vessels, and the heart, is, I believe, to be explained by the fact that all are supported and held in position by the loose meshed mediastinal tissue, which allows for their displacement after the manner observed in the case of the vessels and nerves lying in the loose tissue of the great vascular clefts. _Wounds of the heart._--Perforating wounds of the heart were probably fatal in all instances, in spite of the fact that, in some patients who survived, the position of wound apertures on the surface of the body made it difficult to believe that the heart had not been penetrated. (See cases below.) In the case of this organ, we must bear in mind its constant variations in bulk, its elastic compressibility, and its variations in position in systole and diastole. The variations in bulk and position would be capable of explaining the escape of the organ from injury at some particular moment, when a second shot apparently through the same wound track might implicate it. Beyond this, reasoning from the case of analogous hollow viscera, as the arteries or the intestine, a bullet might readily score the surface of the heart without perforating its cavity. Such accidents were observed. Thus, in a case examined by Mr. Cheatle, the patient died of suppurative pericarditis, secondary to a wound of which the external apertures had closed. In this patient both auricle and ventricle were scored externally by the passage of the bullet. I am, however, disinclined to allow that many patients survived direct blows on the heart, since I believe that in the majority if not in all cardiac wounds the actual cause of death was not hæmorrhage, but sudden stoppage of the heart's action. This is to be inferred from the fact that severe external hæmorrhage did not occur; in some cases the shirt was hardly stained, and in all death occurred in the course of a very few minutes. Again, in none of the patients whom I saw who had received possible wounds of the heart-wall were there evident signs of hæmo-pericardium. In view of the difficulty of detecting this condition from physical signs, this argument is naturally not of great weight, but must be allowed. One or two death scenes from cardiac wound were described to me. In one the patient muttered 'They have got me this time,' and died quietly; in a second the patient's face became ghastly pale, he lay on his back with the knees flexed, clutching the ground, gasping for breath, and died only after some minutes of evident great agony. The absence of any _post-mortem_ details as to the condition of the heart in these injuries is much to be regretted. (145) _Entry_, in the seventh left intercostal space, in the posterior axillary line; _exit_, immediately below the ninth costal cartilage, close to the position of the gall bladder. This track in all probability involved the diaphragm twice, both lungs and pleuræ, and passed immediately beneath the heart. The liver was also perforated, but the spleen and stomach probably escaped as far as could be judged from the symptoms. The patient afterwards developed a pneumo-hæmo-thorax on the right side. The immediate symptoms were great distress in breathing and rapid irregular pulse. The difficulty in respiration was probably in part accounted for by the injuries to the lung and diaphragm. The pulse remained from 112 to 120 for three days, at first soft and hardly perceptible, later very irregular, and dropping one every fifth or sixth beat; and it seemed fair to attribute this to the shock to the nervous mechanism of the heart. The patient recovered from the chest injury. In some other patients in whom the track passed close below the heart a disturbance of the pulse rate was noted, but this was in some cases a slowing, not below 48, in others quickening to 100, with irregularity both in force and beat. (146) _Entry_, in the fourth right interspace, 3 inches from the middle line; _exit_, in the seventh left interspace, in the mid-axillary line. This wound was received at a distance of 500-600 yards, but the bullet penetrated both sides of a stout silver cigarette case and some cigarettes before entering the body. There were minor signs of pulmonary injury, 'coughing day and night,' and slight discoloration of the sputum on three or four occasions. The respirations were quickened to 32, and as much as ten days after the injury the pulse only beat 48 to the minute; it then rose to 56, but beat in a very deliberate manner. In other cases the signs were almost nil. (147) _Entry_, in the fourth right intercostal space 3/4 of an inch from the sternum; _exit_, in the sixth left interspace in the posterior axillary line. This patient had no symptoms, beyond quickening of the pulse to 100, and a 'feeling of tightness at the heart.' He shortly returned to active duty. (148) _Entry_, situated in the third right interspace 3 inches from the sternal margin; _exit_, in the fourth left space 2-3/4 inches from the sternal margin. In this case the bullet without doubt passed through the anterior mediastinum, and slight injury to the lung was evidenced by transient hæmoptysis. Some remarks regarding wounds of the thoracic vessels have already been made in Chapter IV., where instances of injury to the innominate and left subclavian arteries are recounted. The escape of the large trunks was generally quite as astonishing as in other parts of the body, especially in the superior mediastinum. (149) _Entry_, over the first right intercostal space beneath the centre of the clavicle; _exit_, at left anterior axillary fold. The great vessels must have been crossed here in immediate contact, and considerable hæmorrhage from the wound of entry caused great anxiety; this ceased spontaneously, however, and, beyond transient hæmoptysis and a right pneumo-thorax, no further trouble occurred. (150) _Entry_, in the ninth interspace, just anterior to the anterior axillary line; _exit_, through the right half of the sternum, 1/2 an inch below the upper border. No primary hæmorrhage of importance followed, but I believe this patient subsequently died. The wound was received at a range of within fifty yards. _Wounds of the lungs._--Numerically, pulmonary wounds formed the most important series of visceral injuries met with in the thorax, the frequency of incidence corresponding with the proportionate sectional area occupied by the organs. Although these injuries did well, and needed little interference on the part of the surgeon, many points of interest were raised by them. Thus the comparative importance of the wound in the chest-wall to that in the lung itself, was scarcely what, without actual experience, would have been expected, the former proving so very much the more important element of the two. The question of velocity on the part of the bullet took a very secondary position in these injuries. I saw a number of cases in which the patients estimated the range at which they received their wounds as from 30 to 50 yards, and although some of the wounds were of a severe type, the increased gravity depended rather on the injury to the chest-wall than to that of the lung. If the bullet passed by the intercostal space, avoiding the rib, I very much doubt if the relative velocity was of any importance, further than from the fact that a sufficiently low degree to allow of lodgment of the bullet was distinctly unfavourable. In view of the general lack of significance in these injuries it was interesting to note how very definite was the ill effect of early transport on the after course. This depended on the frequent development of parietal hæmothorax in patients who were not kept absolutely at rest. The tracks produced in the lungs by the bullets were very minute, and in the few cases in which opportunity arose for their examination _post mortem_ some little time after the infliction of the wound, there was great difficulty in localising them. The slight damage incurred by the pulmonary tissue is due to its elasticity and non-resistent character. Pulmonary hæmothorax was distinctly rare. Reasoning from the analogous wounds of the liver, tracks scoring the surface of these organs might be much more to be feared than clean perforations. The elasticity of the lung tissue, however, must make such lesions rare. In point of fact, there is no reason why a perforation by a bullet of small calibre should be much more feared than a puncture from an exploring trocar, and the danger of the two wounds is probably very nearly the same. The only points of importance as to the particular region of the lung traversed were the distance from the periphery as affecting the probable size of the vessels injured, and perhaps the implication of the base or apex of the organ respectively. I am under the impression that wounds in the apical region were somewhat more liable to be followed by the development of pneumothorax, and possibly hæmothorax, while wounds at the base gained their chief importance from the frequency of concurrent injury to the abdominal viscera. I had no experience of the immediate results of wound of the great vessels at the root of the lung, but assume that they led to speedy death. _Symptoms of wound of the lung._--I shall describe the whole complex usually observed, although it is obvious that the wound of the chest-wall is responsible for a large proportion of the signs. The majority of these injuries were accompanied by a certain degree of systemic shock, and this was more marked in wounds received at a short range. The shock was, however, rather to be attributed to the injury to the chest-wall and thoracic concussion than to that to the lung itself. I think it may also be stated that few patients were inclined to walk or remain in the erect position after receiving these wounds; this feature was also noted in horses in whom a bullet passed through the lungs. The remarks made as to the pain accompanying fractures of the ribs apply equally here. Pain was not a prominent symptom, except in so far as the actual impact caused temporary suffering. It was striking how often patients who received wounds through the arm prior to the same bullet traversing the chest appreciated the chest wound only, yet the chest might pass unnoticed when a still more sensitive part was struck later, as has been already mentioned in the section on wounds in general. Dyspnoea was not a prominent primary symptom. The patients sometimes had 'all the wind knocked out of them' at the moment of impact, but when seen at the Field hospitals a short time later, the respirations were shallow, but easy and regular, and only moderately quickened; thus 24 was a not uncommon rate. Naturally if accumulation of blood in the pleura began early and continued, these remarks do not hold good; and again in some older men of full-blooded type and the subjects of recurrent attacks of bronchitis, a considerable degree of pain, dyspnoea, and even cyanosis was sometimes present soon after the injury. The complication of wound of the diaphragm has already been referred to in this relation. Local respiratory immobility of the thoracic parietes and consequent asymmetry of movement were constant. This was especially a marked feature when the upper part of the chest was implicated on one side only. It rather corresponded, however, to the local shock observed in wounds of the limbs than to the instinctive immobility accompanying fractures of the ribs; since, as already explained, small-calibre bullet wounds of the ribs are not necessarily painful on movement, and the sign existed even when the bullet had passed by an intercostal space. This sign was naturally a transitory one. Hæmoptysis was a fairly constant sign, but sometimes quite absent when no doubt could exist as to the perforation of the lung. As a rule, a considerable quantity of blood might be coughed up shortly after the injury; but I never knew this to be sufficient in amount to give rise to any misgivings as to danger from the hæmorrhage. After the first evacuation of blood from the wounded lung, the sign varied much; in the majority of instances the patients continued to expectorate small quantities of blood mixed with mucus, for some three or four days, the blood gradually assuming a coagulated condition. Sometimes only the primary hæmoptysis was noted, and still more rarely the expectoration of clots was continued for a week, or even longer. This probably depended partly on personal idiosyncrasy, partly on the size of the vessels which had been implicated in the track. Cough was not commonly the troublesome symptom noted in the contused wounds of the lung seen in civil practice accompanying fracture of the ribs. Moist sounds were usually audible on auscultation, but in many cases over a very limited area and only on the first few days. Cellular emphysema was distinctly rare, and usually limited in extent: thus I saw it in the posterior triangle of the neck alone in an apical wound; over about a third of the upper part of the thorax in another wound through the second intercostal space, and in this case oddly enough the emphysema was the only sign of injury to the lung; and very occasionally widely distributed--in the latter case there were also usually multiple fractures of the ribs. Neither issue of air from the external wound nor frothy blood was ever seen with small-calibre wounds, but I saw one instance in a case of Martini-Henry wound. _Pneumothorax_ was also rare. I saw pneumothorax three times out of about half a dozen Martini-Henry wounds, but I do not think it occurred as often in 100 small-calibre wounds. The Martini-Henry wounds all recovered; but convalescence was very prolonged, and the same remark to a less degree holds good in the small-calibre cases. That the slow recovery in cases of pneumothorax in the Martini-Henry wounds was due mainly to the size of the opening in the thoracic parietes was, I think, proved by the fact that in the small-calibre bullet wounds, followed by the development of pneumothorax, the external wounds were usually large and irregular in type; also, that in the only pneumothorax which I saw produced during an extraction operation, the air was very rapidly absorbed. In the latter case, however, there was little reason to conclude that wound of the lung had occurred primarily, and certainly no opening existed at the time the thorax was incised. _Hæmothorax._--This was the most frequent and also the most interesting of the complications of wound of the chest. In 90 per cent. or more of the cases, the hæmorrhage was of parietal source, and due either to direct injury to the intercostal vessels by the bullet or to laceration by spicules of comminuted ribs. For this reason, the passage of the bullet whether by an intercostal space, or through a rib, provided the wound was not at the posterior part of the space where the artery crosses, was a point of considerable prognostic importance. Exclusion of the lung as the source of hæmorrhage was, I think, amply justified by the absence of continuous recurrent or progressive hæmoptysis in the majority of the cases, and by the very small trace of injury found in the lungs of patients who died some weeks after the injury. In such it was difficult to discriminate the tracks at all. I only happened to see one case where free hæmoptysis, during the course of development of a hæmothorax, pointed to the lung as the source of the blood. Hæmorrhage into the pleural cavity occurred in some degree in a very large proportion of the chest wounds, but it was especially interesting to note how greatly its extent was influenced by the amount of transport to which the patients were subjected in the early stages after the injury. During the early part of the campaign, on the western side, I saw a large number of chest wounds, and had I been asked my opinion as to the relative frequency of occurrence of hæmothorax I should have placed it at about 30 per cent. The patients in these early battles needed little wagon transport, and when sent down to the Base travelled in comfortable ambulance trains. After the commencement of the march from Modder River to Bloemfontein, however, these conditions were changed, and all the chest as other cases were exposed to the necessity of three days and nights' journey to the Stationary hospitals and afterwards to the long journey to Cape Town. Of these patients, at least 90 per cent. suffered with hæmothorax of varying degrees of severity. In some cases, the least common, signs of considerable intra-pleural hæmorrhage immediately followed the wound; in others, the accumulation of blood was gradual, and only manifest in any degree at the end of three or four days, when it became stationary if the patient was kept at rest. In a second series the hæmorrhage was of the recurrent variety; these cases differing little in character from those of slight continuous hæmorrhage. In a third, the bleeding was definitely of a secondary character, corresponding with one of the classes of secondary hæmorrhage described in Chapter IV., and occurring on the eighth or tenth day from giving way of an imperfectly closed wounded vessel. In either of the two latter classes the development of the hæmothorax often corresponded with a journey, or with allowing the patient to get up. The general course of these effusions was towards spontaneous absorption and recovery. Coagulation of the blood took place early, the fluid serum separated, and tended to undergo absorption with some rapidity, leaving a small amount of coagulum at the base, which evidenced its presence for many weeks by a persistence of a certain degree of dulness on percussion. Early coagulation, I think, accounted for the usual absence of gravitation ecchymosis as a sign. The course to recovery was sometimes broken by signs of slight pleuritic inflammation, which, as affecting the amount of effusion, will be spoken of under the heading of symptoms. In some cases the amount of blood was so great as to necessitate means being taken for its removal; in these a reaccumulation often took place. Occasionally an empyema followed in cases thus treated. The nature of the blood evacuated on tapping varied much. In very early aspirations unchanged blood was often met with, but clot sometimes made evacuation difficult and necessitated a second puncture. In the tappings done at the end of a week or more a dark porter-like fluid was common, while when suppuration was imminent a brick-red-coloured grumous fluid replaced normal blood. In the cases where early incision was resorted to, blood both fluid and in clots was often mixed with a certain proportion of lymph flakes, perhaps indicating the part taken by inflammatory reaction to the irritation of the clot in producing the rise of temperature. _Symptoms of hæmothorax._--In the more severe cases of primary bleeding the symptoms did not, as a rule, reach their full height until the third or fourth day after the injury. The patients then often suffered severely. The pulse and temperature rose, and to general symptoms of loss of blood were added: occasional lividity of countenance; severe dyspnoea, accompanied by inability to lie on the sound side or to assume the supine position; absence of respiratory movement on the injured side; pain, restlessness, cough, and sometimes continuance of hæmoptysis, small clots usually being expectorated. Accompanying these symptoms were the usual physical signs of fluid in the pleura in differing degrees and combination. Dulness of varying extent up to complete absence of resonance on one side, often accompanied in the incomplete cases by well-marked skodaic resonance anteriorly. Loss of vocal resonance, and fremitus; oegophony, tubular respiration over the root of the lung or at the upper limit of the dulness, and more or less extensive displacement of the heart. Obvious increase in girth, fulness of the intercostal spaces, or gravitation ecchymosis was rare. The latter was most common in instances in which multiple fracture of the ribs existed (see fig. 83). I think the rarity of the last sign must have been due to the early coagulation of the blood, and its retention by the pleura, as I saw well-marked gravitation ecchymosis in one or two cases of mediastinal hæmorrhage. The above complex of symptoms was common to all the cases, but in the slighter ones they gave rise to little trouble, and cleared up with great rapidity. [Illustration: FIG. 83.--Gravitation Ecchymosis in a case of Hæmothorax, accompanying fracture of three ribs from within. The influence of the fractures on the development of the ecchymosis is shown by the linear arrangement of the discoloration] The most interesting feature was offered by the temperature, as this was very liable to lead one astray. A primary rise always occurred with the collection of blood in the pleura, this reaching its height on the third or fourth day, usually about 102° F. in well-marked cases; it then fell, and in favourable instances remained normal. In a large number of cases, however, where the amount of blood was considerable, this was not the case, the primary fall not reaching the normal, and a second rise occurred which reached the same height as before or higher. The second rise was accompanied by sweating, quickened pulse, and the probability of the development of an empyema had always to be considered. I believe in most cases this secondary rise was an indication of a further increase in the hæmorrhage, for the dulness usually increased in extent, and such rises were often seen when the patient had been moved or taken a journey. Again, the temperature often fell to normal after paracentesis and removal of the blood, to rise again with a fresh accumulation, which was not uncommon. I have already mentioned the large proportional incidence of hæmothorax observed in the patients who had to travel down from Paardeberg, and I might instance another case related to me by Dr. Flockemann of the German ambulance, which was very striking. A Boer, wounded at Colesberg, developed a hæmothorax which quieted down, and he was removed to Bloemfontein; on arrival at the latter place the temperature rose, and other signs of fever suggested the development of an empyema; an exploring needle, however, only brought blood to light. After a short stay at Bloemfontein the symptoms entirely subsided, and the man was sent to Kroonstadt, when an exactly similar attack resulted, again quieting down with rest. Similar recurrent attacks of hæmorrhage and fever occurred, however, in patients confined to their beds without moving after the first journey. Some temperature charts, in illustration of this point, are added to the cases quoted later. The explanation of the recurrent hæmorrhages is, I think, to be found in the reduction of the intra-thoracic pressure with coagulation and shrinkage of the clot in the pleura in the patients kept quiet in bed, while in the patients who had to travel it was probably the result of direct mechanical disturbance. In many of these cases a pleural rub was audible at the upper margin of the dulness with the development of the fresh symptoms. Whether this was due to actual pleurisy or to the rubbing of surfaces rough from the breaking down of slight recent adhesions which had formed a barrier to the effusion, I am unable to say, but the signs were fairly constant. In some instances the increase in the amount of fluid was, no doubt, due to pleural effusion resulting from irritation from the presence of blood-clot, or perhaps the shifting of the latter; in these the secondary rise of temperature may well be ascribed to the development of pleurisy. I am inclined to believe, however, that the primary rise of temperature was similar to that seen when blood accumulates in the peritoneal cavity as the result of trauma, and the secondary rises in most cases to those which we saw so frequently accompanying the interstitial secondary hæmorrhages spoken of in Chapter IV., and are to be explained on the theory of absorption of a blood ferment. The secondary rises always occurred with a fresh effusion, often of blood, occasioning an extension, which broke down probable light adhesions and exposed a fresh area of normal pleural membrane to act as a surface for absorption. It is, of course, manifest that the fever might also be ascribed to the infection of the clot or serum from without, and in the first cases I saw I was inclined to take this view, since we had in every case the primary wounds of chest-wall, and possibly of lung, and in some the addition of a puncture by an exploring needle between the first and second rise. After a wider experience, however, I abandoned the infection theory, as it seemed opposed by the very infrequent sequence of suppuration. The effect of simple removal of the blood or serum was also often so striking as to strongly suggest that it alone was responsible for the fever. Exactly the same result, moreover, followed evacuation of the interstitial blood effusions already mentioned elsewhere. The common course of all the cases of hæmothorax was to spontaneous recovery, the rapidity of the subsidence of the signs depending mainly on the quantity of the primary hæmorrhage, and the occurrence of further increases. The blood serum tended to collect at the upper limit of the original blood effusion (as was often proved on tapping), and this was first absorbed; the clot deposited on the pleural surface and at the basal part of the cavity was, however, not absorbed with the same rapidity. In the majority of the patients when they left the hospitals, at the end of six weeks on an average, some dulness and deficiency of vesicular murmur always remained, and the clot and the surrounding surface, irritated by its presence, will, no doubt, be responsible for permanent adhesions in many cases. That such adhesions do form in the majority of cases I feel certain, as, although these patients when they left the hospital were to all intents and purposes apparently well, few of them could undertake sustained exertion without getting short of breath, and sometimes suffering from transitory pain, and for this reason it became customary to invalid them home. In a small proportion of the cases empyema followed; but I never saw this in any case that had neither been tapped nor opened, and I saw only one patient die from a chest wound uncomplicated by other injuries. This case was an interesting one of recurrent hæmorrhage followed by inflammatory troubles:-- [Illustration: TEMPERATURE CHART 2.--Secondary Hæmorrhages in a case of Hæmothorax. Case No. 151] (151) The wound was received at short range, probably at from 100 to 200 yards. _Entry_, 1 inch from the left axillary margin in the first intercostal space; _exit_, at the back of the right arm 1-1/2 inch below the acromial angle; both pleuræ were therefore crossed. The patient expectorated at first fluid, then clotted, blood in considerable quantity. When brought into the advanced Base hospital on the third day, there were signs of blood in the left pleura, cellular emphysema over the right side of the chest, and signs of collapse of the right lung. The temperature chart gives shortly the course of the case: the right pneumo-thorax cleared up spontaneously, also the emphysema; but the left pleura needed tapping to relieve symptoms of pressure on four occasions, the 13th, 15th, 19th, and 25th days respectively. On the first two occasions blood was removed, on the third blood serum only, and on the last pus. The patient was relieved after each aspiration; after the third, the temperature fell to normal, the general condition also improved, and he promised to do well. None the less, reaccumulation took place, the evacuated fluid assumed an inflammatory character, and an incision to evacuate pus was eventually followed by death on the twenty-seventh day. The amount of hæmoptysis throughout was considerable, and the case was possibly one of pulmonary hæmothorax, as after death no source of hæmorrhage could be localised in the intercostal space. The track in the lung was almost healed, and although a part of it allowed the introduction of a probe for about an inch, it could be traced no further even on section of the organ, and no special vessel could be located as the original bleeding spot. _Empyema._--I may here add the little that I have to say on this subject. During the whole campaign the single case of primary empyema that I saw was the one recorded below, which deserves special mention as illustrating the disadvantage of extracting bullets on the field. Under the conditions which necessarily accompanied this operation the ensurance of asepsis was impossible, and the additional wound no doubt proved the source of infection. (152) _Entry_, at the posterior margin of the sterno-mastoid muscle, 2 inches above the clavicle; the bullet came to the surface beneath the skin over the fifth rib, in the nipple line of the right side. There was never any hæmoptysis, but the patient suffered with some dyspnoea throughout. After a three days' stay in the Field hospital, where the subcutaneous bullet was removed, the patient was transported by wagon and train to the Base, a journey of about 600 miles. On the fifth day pus escaped from the extraction wound, and when the case was examined at the Base, the temperature was 101°, the pulse over 100, the respirations 30, and the whole side of the chest was dull, with the exception of a patch of boxy resonance over the apex anteriorly. On the following day the chest was drained, and a considerable amount of pus evacuated, which was mixed with breaking-down blood-clot. A fortnight later a second operation had to be performed to improve the drainage, and the patient made a tedious recovery. The following case well illustrates the symptoms in a severe case of hæmothorax, and empyema following aspiration:-- (153) The patient was wounded at Paardeberg at a range of from 500 to 700 yards. _Entry_, just to the left of the episternal notch; _exit_, in the fifth left interspace posteriorly, midway between the spine and vertebral margin of the scapula. A quantity of bright blood was brought up at once, and later blood was coughed up in clots. There was no great pain at the moment of the injury; the man again got up to the firing line, and later walked two miles to the Field hospital without aid. He remained here a week, when he was sent down to the Base, and during the first three days' journey in the wagon he began to get worse. On the fourth day cough began to be very troublesome. When he arrived at the Base, fifteen days after the original injury, there was much dyspnoea; the temperature was 102°, and the pulse 110. The left side of the chest was dull throughout; an aspirating needle was introduced, and a pint of very dark liquid blood drawn off. The whole of the blood was not removed on account of the very severe cough and pain which the evacuation occasioned. The man appeared to steadily improve until three weeks later, when the temperature, which throughout had been uneven, became consistently high, and signs of fluid at the base increased. An aspirating needle was introduced, and 16 ounces of pus were drawn off. Two days later a piece of rib was resected (Mr. Pegg) and another pint of pus evacuated. After this, rapid improvement took place, and in ten days the man was able to be up and dressed, although a small amount of discharge still persisted. He eventually made an excellent recovery. Secondary empyemata not uncommonly followed incision of the chest, or excision of a rib for draining a hæmothorax. These operations in the early part of the campaign were more freely undertaken on the supposition that rise of temperature and other symptoms of fever pointed to incipient breaking down of the clot. Subsequent experience showed this not to be the case, and early operations for drainage ceased to be undertaken. In these operations a primary difficulty was met with in effectively clearing out the clot, a drain had to be left, and suppuration occurred later in a considerable proportion. The suppurations were most troublesome; local adhesions formed, and the pus collected in small pockets, which were difficult to find and to drain, and even when the collections seemed to have been successfully dealt with at the time, residual abscesses often followed at a very late date. Thus, I saw a case with a contracted chest and a fresh abscess the day before I left Cape Town, in whom I had advised and witnessed an operation for the evacuation of clot in the presence of signs of fever a week after my arrival in the country, nine months previously. I saw another case where general infection followed incision of a hæmothorax, but the patient fortunately recovered. The question of _pleurisy_ has already been mentioned in connection with hæmothorax; it no doubt accounted for secondary effusion in some cases, and beyond this I have nothing to add to what has been there said. _Pneumonia_ was rare; there were occasionally signs of consolidation, but, I think, quite as often in the opposite lung as in the one injured. I never saw a fatal case, and I am inclined to think that when it occurred it was as often the result of cold and exposure as of the injury to the lung. Abscess of the lung I only saw once, and that in a case in which the injury to the chest was complicated by paraplegia from spinal injury and septicæmia, and it was possibly pyæmic. _Diagnosis._--No difficulties special to small-calibre wounds were experienced, except such as have been already dealt with. The only class of case which frequently gave rise to difficulty was hæmothorax. Here two points especially needed consideration. (1) _The source of the hæmorrhage as parietal or visceral._ As has been already foreshadowed, this was mainly to be decided by the amount and persistence of the hæmoptysis, but naturally free hæmoptysis did not negative concurrent parietal bleeding. Then the actual source of the bleeding other than from the lung had to be considered; in the great majority of cases the intercostal vessels were responsible, and attention to the course of the tracks often allowed this to be definitely decided upon. A case included in the chapter on Injuries to the Blood Vessels (No. 5, p. 127) is of great interest in this particular; in that instance feebleness of the radial pulse, together with the position of the wound, was a valuable indication of injury to the subclavian artery, but weakened somewhat by the fact of retention of the bullet, and hence uncertainty as to the exact course that it had taken, and as to whether the bullet itself was not responsible for pressure on the vessel. Such indications, however, should make one very chary of interference with a hæmothorax, even with extremely urgent symptoms, in the light of our present knowledge of the nature of the lesions to the great vessels produced by small-calibre bullets, and their tendency to be incomplete. (2) _The imminence of suppuration or its actual occurrence._--In most cases it sufficed to preserve an expectant attitude, and in the persistence or increase of symptoms, to have recourse to an exploratory puncture as the best means of solution of the difficulty. _Prognosis._--The prognosis both as to life and as to subsequent ill-effects was remarkably good; in many cases of uncomplicated injury to the lung the patients rejoined their regiments at the end of a month or six weeks. In the more serious cases complicated by the collection of blood in the pleura, convalescence was more prolonged, and an average time of six to eight weeks often elapsed before the patients could be safely discharged from hospital. In the more serious a certain amount of dulness always persisted at this time over the base of the lung, and the chest was usually somewhat contracted on the injured side, with evidence in the way of decreased vesicular murmur that the lung was still not free from compression. With regard to the persistence of dulness on percussion, it is well to bear in mind that a thin layer of blood apparently produces as serious impairment of resonance as a much larger quantity of serum. The signs appeared to favour the view that the space necessary for the location of the hæmorrhage had been obtained at the expense of the lung rather than by distension of the thoracic parietes, and also, I think, denoted the presence of adhesions. Possibly they will entirely disappear with the return of full excursion movements of respiration, the latter being often still somewhat restricted when the patients left hospital. All the patients with such signs were liable to attacks of pain and shortness of breath on actual bodily exertion. I happened to meet with an officer, the subject of a Lee-Metford wound of the thorax, sustained five years previously, and he told me that he was nine months before he could take active exercise without feeling short of breath. As to the cases of hæmothorax and empyema which needed drainage, all did well; but expansion of the lung was much less satisfactory than would have been expected, probably on account of especially firm adhesions. The importance of concurrent injury I need hardly dwell on; but I might add that perforation of one or both arms, the most common one, did not materially affect the general statements above made. _Treatment._--In the early stages of the pulmonary wounds rest was the all-important indication, and when this was assured few serious cases of hæmothorax occurred. Beyond simple rest, the administration of opium with a view to checking internal hæmorrhage was used with good effect. The wounds needed simple dressing only. The treatment of hæmothorax at a later date, however, was of much interest and difficulty. I think the following lines may be laid down for guidance in such cases:-- (i) Hæmothorax, even of considerable severity, will undergo spontaneous cure. An early rise of temperature may be disregarded. (ii) Tapping the chest is indicated when pressure signs on the lung are sufficiently severe to cause serious symptoms, and the removal of the blood undoubtedly shortens the period of recovery, as well as relieves symptoms. In such cases the collection of blood has usually been rapid and continuous; hence a fresh hæmorrhage is always probable when the local pressure has been removed. Tapping therefore should not necessarily mean complete evacuation, and should be followed by careful firm binding up of the chest, the administration of opium, and the most stringent precautions for rest. (iii) Tapping may be needed as a diagnostic aid, and in such circumstances as much fluid as can be removed should be evacuated with the same precautions as mentioned in the last paragraph. (iv) Tapping may be indicated for the evacuation of serum expressed from the blood-clot, or due to pleural effusion, on the same lines as in any other collection of fluid in the pleural cavity. (v) Early free incision is, as a rule, to be steadfastly avoided. Some cases already quoted fully illustrate its disadvantages. (vi) Cases in which an incision and the ligature of a parietal artery are indicated are very rare. I never saw such a one myself. (vii) If a hæmothorax suppurates, it must be treated on the ordinary lines of an empyema. In view of the constant formation of adhesions and difficulty in drainage, a portion of a rib should always be resected in order to ensure sufficient space for after-treatment. The cavities, as a rule, are better irrigated, the usual precautions being taken where there is any reason to fear that the lung is still in communication with the cavity. Care in carrying out asepsis in tapping, which should be performed with an aspirator, need hardly be more than mentioned. It will be noted that in some of the cases quoted suppuration followed tapping, but it must be remembered that in these the two primary wounds already existed as possible channels of infection. Retained bullets of small calibre in the thoracic cavity were not common, unless the lodgment had occurred in the bodies of the vertebræ. I saw very few. Shrapnel bullets and fragments of shells, however, were, in proportion to the frequency of wounds from such projectiles, more commonly retained. The rules to be followed in such cases do not materially deviate from those to be observed in the body generally. When the bullet is causing no trouble, and is lodged in either the bone of the spine or the lung substance, no interference is advisable. When, on the other hand, the bullet as viewed by the X-rays is seen to be in the pleural cavity, and any symptoms of its presence exist, it may be justifiable to remove it. I saw this done in one case for the removal of a shrapnel bullet from the lower reflexion of the pleura on account of fixed pain and tenderness complained of by the patient. The bullet, a shrapnel, had perforated the arm, which the patient was sure was by his side at the moment of injury, and the X-rays showed it to lie at the bottom of the pleural cavity, where we assumed it had fallen. When, however, the bullet was removed by Mr. Watson, he found that the fixed pain and tenderness had been the result of a fracture of a rib from the inner side, not involving loss of continuity; hence the actual indication for the operation had been a delusive one, since the bullet had not fallen, but expended its last force in injuring the rib. The patient made an excellent recovery, and rejoined his regiment at the end of six weeks. I saw several cases in which the bullet was lodged in either the lung or bones of the spine do well with no interference. The great disadvantage of primary removal in inducing an artificial pneumo-thorax and in laying open a hæmothorax is obvious. In case of lodgment of the bullet in the lung, bearing in mind the infrequency of untoward symptoms, the latter should be watched for prior to interference. The following cases illustrate some typical instances of wound of chest accompanied by the development of hæmothorax:-- [Illustration: TEMPERATURE CHART 3.--Primary Hæmothorax, with rise of temperature. Secondary rise, with fresh effusion and pneumonia. Spontaneous recovery. Case No. 154] (154) _Severe hæmothorax. Spontaneous recovery._--Wounded at Modder River at a distance of 30 yards. _Entry_, at the junction of the left anterior axillary fold with the chest-wall; _exit_, immediately to the left of the seventh dorsal spinous process. The patient arrived at the Base with signs of an extensive hæmothorax, accompanied by a temperature which reached 102° on the fourth day, and on the evening of the tenth 103°. The man was very ill, and an exploring needle was inserted, by which about an ounce of blood was evacuated. The signs of fluid in the left pleura were accompanied by those of consolidation over the lower fourth of the right lung, and the sputa were rusty. Evidence of perforation of the left axillary artery existed in feebleness of the radial pulse; and there was musculo-spiral paralysis. After the preliminary puncture, the man refused any further operative treatment, although a second rise of temperature commenced on the fifteenth day, culminating in a temperature of 103.2° on the eighteenth. The further treatment of the patient consisted in the ensurance of rest and the alleviation of pain. A steady fall in the temperature extended over another three weeks, together with diminution in the signs of fluid in the pleura. At the end of seventy-four days the man was sent home, some slight dulness at the left base, and contraction of the chest sufficient to influence the spine in the way of lateral curvature, being the only remaining signs. [Illustration: TEMPERATURE CHART 4.--Primary Hæmothorax. Secondary rise of temperature, with increase in the effusion. Spontaneous recovery. Case No. 155] (155) _Severe hæmothorax. Secondary effusion. Spontaneous recovery._--Wounded at Koodoosberg Drift, at a distance of 200 yards. _Entry_, at angle of the right scapula; _exit_, at the junction of the left anterior axillary fold with the chest-wall. No signs of spinal cord injury. The patient was brought in from the field twelve miles by an ambulance wagon on the second day, and in crossing the Modder River he was accidentally upset into the stream. For the first four days there was no hæmoptysis, but for the succeeding nine days small brightish red clots were expectorated. There was some tenderness over the ribs from the fifth to the ninth in the axillary line, and on the ninth day some gravitation ecchymosis appeared over the same region. Cough was an early troublesome symptom in this case, and when admitted to the Base hospital, about the seventh day, there was evidence of fluid extending about a third of the way up the back. On the tenth day after admission a pleural rub was detected at the upper margin of the dulness, and the latter shortly extended upwards over a little more than half the back. Meanwhile, there was no further hæmoptysis, respiration was fairly easy, 24 per minute, but accompanied by slight dilatation of the alæ nasi, and the temperature, which had been ranging from 99° to 100°, began to rise steadily, on the fifteenth day reaching 102.5°. The patient refused even an exploratory puncture, and was treated on the expectant plan. The temperature slowly subsided, with a steady improvement in the physical signs, and at the end of about ten weeks he left for home with only slight dulness and incapacity for active exertion remaining. (Now again on active service.) [Illustration: TEMPERATURE CHART 5.--Hæmothorax, primary and secondary rises of temperature, on each occasion falling on the evacuation of the blood. Case No. 156] (156) _Severe hæmothorax. Recurrent secondary effusion. Tapping on two occasions. Cure._--The patient was wounded at Paardeberg, and arrived at the Base on the eighteenth day. _Entry_, below the first rib, just external to its junction with the costal cartilage; _exit_, through the ninth rib, just within the posterior axillary line. The whole right side of the chest was dull, with signs of the presence of fluid, the heart being displaced to the left. There was considerable distress; the respirations averaged 40, the pulse 100, and the temperature reached 101.5° the first evening after arrival. On the nineteenth day the thorax was aspirated (Mr. Hanwell) and 50 ounces of dirty red-coloured fluid, half clot, half serum, were evacuated. Considerable relief was afforded; the respirations became slightly less frequent; the heart returned to a normal position, and distant tubular respiration was audible. The temperature dropped to normal the third day after evacuation of the fluid, but on the sixth day it again commenced to rise, and meanwhile fluid again began to collect. On the twenty-sixth day a second aspiration resulted in the evacuation of 35 ounces of bloody fluid in which flakes of lymph were found. Three days later the temperature became normal. The respirations fell to 22, and the patient made an uninterrupted recovery. [Illustration: TEMPERATURE CHART 6.--Wound of Lung. Secondary development of Hæmothorax, with rise of temperature. Spontaneous recovery. Case No 157] (157) _Moderate hæmothorax. Secondary effusion at the end of twenty days. Spontaneous recovery._--Wounded at Paardeberg; range from 700 to 1,000 yards. _Entry_, in the centre of the second right intercostal space, anteriorly; _exit_, at the level of the sixth rib posteriorly, through the scapula, close to its vertebral margin. The patient arrived at the Base on the sixth day; he said he expectorated some blood at the end of about ten minutes after being shot, and experienced a 'half-choking sensation.' A small quantity of phlegm and occasional clots had been expectorated since. He had walked about a good deal; movement occasioned cough, and he became 'blown' very rapidly. On admission there were signs of fluid in the lower third of the pleural cavity, but no general symptoms beyond an evening rise of temperature to an average of 99°. About the twentieth day the temperature commenced to rise, and on the twenty-third and four following evenings reached 102°. The fever was accompanied by some distress, and a well-marked increase in the physical signs of the presence of fluid in the chest. The pulse rose to 96, and the respirations considerably above the average of 24, which was at first noted. A strictly expectant attitude was maintained, and the temperature steadily fell in a curve corresponding to the rise, gradually reaching the normal at the end of a week. The physical signs at the base steadily cleared up, and at the end of six weeks the patient returned to England convalescent. CHAPTER XI INJURIES TO THE ABDOMEN Perhaps no chapter of military surgery was looked forward to with more eager interest than that dealing with wounds of the abdomen. In none was greater expectation indulged in with regard to probable advance in active surgical treatment, and in none did greater disappointment lie in store for us. Wounds of the solid viscera, it is true, proved to be of minor importance when produced by bullets of small calibre; but wounds of the intestinal tract, although they showed themselves capable of spontaneous recovery in a certain proportion of the cases observed, afforded but slight opportunity for surgical skill, and results generally deviated but slightly from those of past experience. Such success as was met with depended rather on the mechanical genesis and nature of the wounds than upon the efforts of the surgeon, and operative surgery scored but few successes. It is true that to the Civil Surgeon accustomed to surroundings replete with every modern appliance and convenience, and the possibility of exercising the most stringent precautions against the introduction of sepsis from without, abdominal operations presented difficulties only faintly appreciated in advance; but this alone scarcely accounted for the want of success attending the active treatment of wounds of the intestine when occasion demanded. Failure was rather to be referred to the severity of the local injury to be dealt with, or to the operations being necessarily undertaken at too late a date. Many fatalities, again, were due to the association of other injuries, a large proportion of the wound tracks involving other organs or parts beyond the boundaries of the abdominal cavity. The frequent association of wounds of the thoracic cavity with those of the abdomen afforded many of the most striking examples of immunity from serious consequences as a result of wound of the pleura. It must be conceded that in a large number of such injuries only the extreme limits of the pleural sac were encroached upon, yet in some the tracks passed through the lungs, although without serious consequences. Under the heading of injury to the large intestine a somewhat special form of pleural septicæmia will be referred to. It may at once be stated that such favourable results as occurred in abdominal injuries were practically limited to wounds caused by bullets of small calibre, and that, although in the short chapter dealing with shell injuries a few recoveries from visceral wounds will be mentioned, I never met with a penetrating visceral injury from a Martini-Henry or large sporting bullet which did not prove fatal. _Wounds of the abdominal wall._--It is somewhat paradoxical to say that these injuries possessed special interest from their comparative rarity of occurrence, since they were not of intrinsic importance. Their infrequency depended on the difficulty of striking the body in such a plane as to implicate the belly wall alone, and their interest in the diagnostic difficulty which they gave rise to. In many cases the position of the openings and the strongly oval or gutter character possessed by them were sufficient proof of the superficial passage of the bullet; in others we had to bear in mind that the position of the patient when struck was rarely that of rest in the supine position, in which the surgical examination was made, and considerable difficulty arose. Some superficial tracks crossing the belly wall have already been referred to in the chapter on wounds in general and in that dealing with injuries to the chest, in which the above characters sufficed to indicate that penetration of the abdominal cavity had not occurred. In other instances a definite subcutaneous gutter could be traced, and often in these a well-marked cord in the abdominal wall corresponding to the track could be felt at a later date. Again, limitation to the abdominal wall was sometimes proved by the position of the retained bullet, or sometimes by the presence in the track of foreign bodies carried in with the projectile. See case 160. Fig. 84 illustrates an example where the limitation to the abdominal wall was evident on inspection. Here the division of the thick muscles of the abdominal wall had led to the formation of a swelling exactly similar to that seen after the subcutaneous rupture of a muscle, and two soft fluctuating tumours bounded by contracted muscle existed in the substance of the oblique and rectus muscles. [Illustration: FIG. 84.--Wound of Abdominal Wall (Lee-Metford). Division of fibres of external oblique and rectus abdominis muscles. Case 159] The cases which presented the most serious diagnostic difficulty in this relation were those in which the wound was situated in the thicker muscular portions of the lower part of the abdominal and pelvic walls. Such a case is illustrated in the chapter on fractures (see fig. 55, p. 191). I saw one or two such instances, in which only the exploration necessary for treatment of the fracture decided the point. In many of the wounds affecting the lateral portion of the abdominal wall the question of penetration could never be definitely cleared up, as wounds of the colon sometimes gave rise to absolutely no symptoms. In a certain proportion of the injuries the peritoneal cavity was no doubt perforated without the infliction of any further visceral injury, and in these also the doubt as to the occurrence of penetration was never solved. (158) _Wound of belly wall._--Wounded at Modder River. _Entry_ (Mauser), 2 inches below the centre of the left iliac crest; _exit_, 1-1/2 inch above and internal to the left anterior superior iliac spine. The patient was on horseback at the time of the injury and did not fall; he got down, however, and lay on the field an hour, whence he was removed to hospital. Probably the track pierced the ilium, and remained confined to the abdominal wall. There were no signs of visceral injury. (159) Cape Boy. Wounded at Modder River. _Entry_ (Lee-Metford), immediately above and outside right anterior superior spine; _exit_, 1-1/2 inch below and to right of umbilicus. A well-marked swelling corresponded with division of the fibres of the oblique muscles and of the rectus, and on palpation a hollow corresponding with the track was felt. The abdominal muscles were exceptionally well developed (fig. 84). (160) Wounded at Magersfontein while lying prone. _Entry_, irregular, oblique, and somewhat contused, over the eighth left rib, in the anterior axillary line; _exit_, a slit wound immediately above and to the left of the umbilicus. The bullet struck a small circular metal looking-glass before entering, hence the irregularity of the wound. The patient developed a hæmothorax, but no abdominal signs; the former was probably parietal in origin, secondary to the fractured rib, and the whole wound non-penetrating as far as the abdominal cavity was concerned. (161) Wounded at Magersfontein. _Entry_ (Mauser), 1-1/2 inch external to and 1/2 inch below the left posterior superior iliac spine; _exit_, 1 inch internal horizontally to the left anterior superior spine. No signs of intra-peritoneal injury were noted, but free suppuration occurred in left loin; the ilium was tunnelled. The same patient was wounded by a Jeffrey bullet in the hand; the third metacarpal was pulverised, although the bullet, which was longitudinally flanged, was retained. (162) Wounded outside Heilbron. _Entry_, below the eighth right costal cartilage; _exit_, below the eighth cartilage of the left side. The wound of entry was slightly oval; that of exit continued out as a 'flame'-like groove for 2 inches. A week later the wound track could be palpated as an evident hard continuous cord. _Penetration of the intestinal area without definite evidence of visceral injury._--This accident occurred with a sufficient degree of frequency to obtain the greatest importance, both from the point of view of diagnosis and prognosis, and as affecting the question of operative interference. Amongst the cases reported below a number occurred in which it was impossible to settle the question whether injury to the bowel had occurred or not, and I will here shortly give what explanation I can for the apparent escape of the intestine from serious injury. We may first recall the general question of the escape of structures lying to one or other side of the track of the bullet. I believe that there can be no doubt as to the accuracy of the remarks already made as to the escape of such structures as the nerves by means of displacement, and that the occurrence of such escapes is manifestly dependent on the degree of fixity of the nerve or the special segment of it implicated. The general tendency of the tissues around the tracks to escape extensive destruction from actual contusion has also been referred to, and is, I think, indisputable. If these observations be accepted, I think there can be no difficulty in allowing that the small intestine is exceptionally well arranged to escape injury. First of all, it is very moveable; secondly, it is so arranged that in certain directions a bullet may pass almost parallel to the long axis of the coils; thirdly, it is elastic, capable of compression, and light, and hence offers but a small degree of resistance to the passage of the bullet across the abdominal cavity. Certain evidence both clinical and pathological supports the contention that the small intestine may escape injury from the passing bullet. First of all, the fact may be broadly stated that injuries to the small intestine were fatal in the great majority of certainly diagnosed cases, while, on the other hand, many tracks crossed the area occupied by the small intestine without serious symptoms of any kind resulting. Secondly, experience showed that when the bullet crossed the line of the fixed portions of the large intestine the gut rarely escaped, and that, although a considerable proportion of these cases recovered spontaneously, in a large number of them immediate symptoms, or secondary complications, clearly substantiated the nature of the original injury. As far as my experience went, however, I never saw any instance in which an undoubted injury of the small intestine was followed by the development of a local peritoneal suppuration and recovery, a sequence by no means uncommon in the case of wounds of the large intestine. Although, therefore, I am not prepared to deny the possibility of spontaneous recovery from an injury to the small intestine, under certain conditions which will be stated later, I believe that in the immense majority of cases in which a bullet crossed the small intestine area without the supervention of serious symptoms, the small intestine escaped perforating injury. Beyond the clinical evidence offered above, certain pathological observations support the view that the intestine escapes perforation by displacement. Most of my knowledge on this subject was derived from the limited number of abdominal sections I performed on cases of injury to the small intestine, and may be summed up as follows. The small intestine may present evidence of lateral contusion in the shape of elongated ecchymoses, either parallel, oblique, or transverse to its long axis. These ecchymoses resemble in extent and outline those which ordinarily surround a wound of the intestinal wall produced by a bullet (see fig. 87, p. 418). The wall of the small intestine may be wounded to an extent short of perforation, either the peritoneal coat alone being split, or the wound implicating the muscular coat and producing an appearance similar to that seen when the intestine is dragged upon during an operation, but without so much gaping of the edges (see fig. 85, p. 416). I met with these conditions in association with co-existing complete perforations of the small intestine, and in one case of intra-peritoneal hæmorrhage in which no complete perforation was discoverable (No. 169, p. 432). The implication and perforation of the small intestine are to some extent influenced by the direction of the wound. A striking case is included below, No. 201, in which a bullet passed from the loin to the iliac fossa on each side of the body, approximately parallel to the course of the inner margin of the colon, and I also saw some other wounds in this direction in which no evidence of injury to the small intestine was detected, and which got well. Again wounds from flank to flank were, as a rule, very fatal; but I saw more than one instance where these wounds were situated immediately below the crest of the ilium, in which the intestine escaped injury (see case 171). A very striking observation was made by Mr. Cheatle in such a wound. The patient died as a result of a double perforation of both cæcum and sigmoid flexure; none the less the bullet had crossed the small intestine area without inflicting any injury. The sum of my experience, in fact, was to encourage the belief that, unless the intestine was struck in such a direction as to render lateral displacement an impossibility, the gut often escaped perforation. As a rule, the wounds of the abdomen which from their position proved the most dangerous to the intestine were-- 1. Wounds passing from one flank to the other were very dangerous, as crossing complicated coils of the small intestine, and two fixed portions of the colon. This danger was most marked when the wounds were situated between the eighth rib in the mid axillary line and the crest of the ilium; above this level the liver, or possibly liver and stomach, were sometimes alone implicated, and the cases did well. Again, when the wounds crossed the false pelvis the patients sometimes escaped all injury to viscera. 2. Antero-posterior wounds in the small intestine area were very fatal if the course was direct; in such the small intestine seldom escaped injury. 3. Wounds with a certain degree of obliquity from anterior wall to flank, or from flank to loin, were on the other hand comparatively favourable, as the small intestine often escaped, and if any gut was wounded, it was often the colon. 4. Vertical wounds implicating the chest and abdomen, or the abdomen and pelvis, were on the whole not very unfavourable. For instance, when the bullet entered by the buttock and emerged below the umbilicus, a number of patients escaped fatal injury; this depended on the comparatively good prognosis in wounds of the rectum and bladder. A good many patients in whom the bullet entered by the upper part of the loin, and escaped 1-1/2 inch within the anterior superior spine of the ilium, also did well. The same holds good when the wounds either entered or emerged under the anterior costal margin of the thorax, either prior to or after traversing the thorax. Wounds passing directly backward from the iliac regions were in my experience very unfavourable; but I believe mainly as a result of hæmorrhage from the iliac arteries. _The occurrence of wounds of the abdomen of an 'explosive' character._--The vast majority of the abdominal wounds observed in the Stationary or Base hospitals were of the type dimensions. A certain number of the abdominal injuries which proved fatal on the field or shortly afterwards were described as explosive in character, and were referred by the observers to the employment of expanding bullets. A few words on this subject seem necessary, because it seems doubtful whether such injuries could be produced by any of the forms of expanding bullet of small calibre in use, unless the track crossed one of the bones in the abdominal or pelvic wall. That this was sometimes the case there is no doubt: thus I saw two cases in which the splenic flexure of the colon was wounded, in which the external opening was large, and a comminuted fracture of the ribs of the left side existed. One can well believe that bullets passing through the pelvic bones might 'set up' to a considerable extent, and although I never happened to see such a case, an explanation of some of the wounds described by others might be found in this occurrence. In instances in which the soft parts alone were perforated, I am disinclined to believe that bullets of small calibre, either regulation or soft-nosed, were responsible for the injuries. I had the opportunity of examining two Mauser bullets of the Jeffreys variety which crossed the abdomen and caused death. In the first (figured on page 94, fig. 40) very little alteration beyond slight shortening had occurred. In the second the deformity was almost the same, except that the side of the bullet was indented, probably from impact with some object prior to its entry into the body. In each case the bullet was of course travelling at a low rate of velocity; hence no very strong inference can be drawn from either. In the case of the second specimen, which was removed by Mr. Cheatle, a remarkable observation was made, which tends to throw some light on one possible mode of production of large exit apertures. This bullet crossed the cæcum, making two small type openings; but later, when it crossed the sigmoid flexure, it tore two large irregular openings in the gut. This might be explained on the ground that the velocity was so small as only just to allow of perforation, which therefore took the nature of a tear. I am inclined to suggest, as a more likely explanation, that the spent bullet turned head over heels in its course across the abdomen, and made lateral or irregular impact with the last piece of bowel it touched. A slightly greater degree of force would have allowed a similar large and irregular opening to be made in the abdominal wall also. In this relation the question will naturally be raised as to how far the explosive appearances may have been due to high velocity alone on the part of the bullet. I am disinclined from my general experience to believe that explosive injuries of the soft parts were to be thus explained. On the other hand, I believe that the possession of a low degree of velocity very greatly increased the danger in abdominal wounds. I believe that the bowel was, under these circumstances, less likely to escape by displacement, and was more widely torn when wounded; again, that inexact impact led to increase of size in the external apertures, and the bullet was of course more often retained. Mr. Watson Cheyne[19] published a very remarkable instance of one of the dangers of an injury from a spent bullet, in which, in spite of non-penetration of the abdominal cavity, the small intestine was ruptured in two places. I believe the majority of the wounds designated as explosive were the result of the passage of large leaden bullets, either of the Martini-Henry or Express type. The small opportunity of observing such injuries in the hospitals of course depended on the fact that the majority were rapidly fatal. _Nature of the anatomical lesion in wounds of the intestine._--The openings in the parietal peritoneum tended to assume the slit or star forms, probably on account of the elasticity of the membrane. A diagram of one of these forms is appended to fig. 89. In this instance the opening in the peritoneum was made from the abdominal aspect, prior to the escape of the bullet from the cavity, and on the impact of the tip, the long axis of the bullet was oblique to the surface of the abdominal wall. In the intestinal wall the openings varied in character according to the mode of impact. In some cases the gut was merely contused by lateral contact of the passing bullet. The result of this was evidenced later by the presence of localised oval patches of ecchymosis. These were identical in appearance with the patches shown surrounding the wounds in fig. 87. [Illustration: FIG. 85.--Lateral Slit in Small Intestine produced by passage of bullet. Slit somewhat obscured by deposition of inflammatory lymph. (St. Thomas's Hospital Museum)] More forcible lateral impact produced a split of the peritoneum, or of this together with the muscular coat. Such a lateral slit is shown in fig. 85, although the clearness of outline is somewhat impaired by the presence of a considerable amount of inflammatory lymph. Fig. 86 exhibits a lateral injury of a more pronounced form. The bullet here struck the most prominent portion of the under surface of the bowel, and produced a circular perforation not very unlike one produced by rectangular impact, except in the lesser degree of eversion of the mucous membrane. Here again the appearance is somewhat altered by the presence of a considerable amount of lymph, but this is of less importance in this figure because the lymph is localised to the portion of the bowel in the immediate neighbourhood of the opening which had suffered contusion and erasion. [Illustration: FIG. 86.--Gutter Wound of Small Intestine caused by lateral impact. Position of shallow portion of gutter indicated by deposition of inflammatory lymph. Circular perforation. (St. Thomas's Hospital Museum)] Fig. 87, A B, illustrates a symmetrical perforation of the small intestine; the aperture of entry (A) is roughly circular, and a ring of mucous membrane protrudes and partially closes the opening. The aperture of exit is a curved slit, again partially occluded by the mucous membrane. The same amount of difference between the two apertures did not always exist; in many cases both were circular, and apparently symmetrical. Beyond this I have seen three apertures in close proximity, two lying on the same aspect of the bowel, and the first of these was no doubt an opening due to lateral impact similar to that seen in fig. 86. In the recent condition little difference existed between the three apertures. The localised ecchymosis surrounding the apertures is quite characteristic of this form of injury, and is a valuable aid to finding the openings during an operation. Fig. 88 shows the interior of the same segment of bowel, as fig. 87. It shows the localised ecchymosis as seen from the inner surface, here rather more extensive from the fact that the blood spreads more readily in the submucous tissue. [Illustration: FIG. 87.--Perforating Wounds of Small Intestine. A. Entry; note circular outline and eversion of mucous membrane. B. Wound of exit; curved slit-like character, eversion of mucous membrane. Note the localised ecchymosis, more abundant round exit aperture. (St. Thomas's Hospital Museum)] It will be noted that the main feature of the form of injury is the regular outline and the small size of the wounds. Another feature not illustrated by the figures should also be mentioned. In the ruptures of intestine with which we are acquainted in civil practice the wound in the gut is almost without exception situated at the free border of the bowel, but in these injuries it was just as frequently at the mesenteric margin. The importance of this factor is considerable, since wounds near the mesenteric edge are much more likely to be accompanied by hæmorrhage, and thus the opportunity for diffusion of infection is considerably multiplied, to say nothing of the danger from loss of blood. Beyond these more or less pure perforations, long slits or gutters were occasionally cut. I saw instances of these in the case of the ascending colon, and in the small curvature of the stomach. The comparative fixity of the portion of bowel struck is a matter of great importance in the production of this form of injury. [Illustration: FIG. 88.--The same piece of Intestine as that shown in fig. 87, laid open to show the ecchymosis on the inner aspect of the Bowel. The two indicating lines lead to the openings, which appear slit-like, and are sunk at the bottom of folds. (St. Thomas's Hospital Museum)] It may be well to add that, although the figures inserted are all taken from small-intestine wounds, the nature of the wounds of the peritoneum-clad part of the large intestine in no way differed from them, except in so far as fixity of the bowel exposed it to a more extensive wound when the bullet took a parallel course to its long axis. A more important point in the injuries to the large intestine was the possibility of an extra-peritoneal wound. I saw several such lesions of the colon, every one of which ended fatally. I became still more fully convinced of the greater seriousness of extra- to intra-peritoneal rupture of this portion of the gut than I was when I expressed a similar opinion in a former paper.[20] It will be seen later that the results of intra- and extra-peritoneal wounds of the bladder fully confirm this view, as all extra-peritoneal injuries died, while many intra-peritoneal perforations recovered spontaneously. _Wounds of the mesentery._--I had little experience of this injury; in fact, case 169, on which I operated, was my sole observation. It stands to reason, however, that injuries to the mesentery would be much more frequent proportionately to wounds of the gut than is the case in the ruptures seen in civil practice, since the whole area of the mesentery is equally open to injury. Viewing the extreme danger of hæmorrhage into the peritoneal cavity in these injuries, I should be inclined to expect that a considerable proportion of those deaths from abdominal wounds which took place on the field of battle were due to this source. _Wounds of the omentum._--Here, again, I am unable to express any opinion, although the supposition that hæmorrhage from this source took place is natural. Prolapse of omentum was comparatively rare, except in cases with large wounds; it was apparently seen with some frequency among patients who died rapidly on the field of battle. I only saw it twice, and on each occasion in shell wounds. The wounds from small-calibre bullets were as a rule too small to allow of external prolapse. Fig. 89, however, illustrates a very interesting observation. A patient in the German Ambulance in Heilbron, under Dr. Flockemann, died as a result of suppuration and hæmorrhage secondary to an injury to the colon. At the autopsy a portion of the omentum was found adherent in the wound of exit, but it had not reached the external surface. The chief interest of the observation lies in the light it throws on the mechanism of these injuries. It is impossible to conceive that a small-calibre bullet coming into direct contact with the omentum could do anything but perforate it. It, therefore, appears clear that in a displacement like that figured, only lateral impact occurred with the omentum, which was carried along by the spin and rush of the bullet into the canal of exit, where it lodged. [Illustration: FIG. 89.--Great Omentum carried by the bullet into an exit track leading from the abdominal cavity. A. Outline of opening in the peritoneum] _Results of injury to the intestine._ 1. _Escape of contents and infection of the peritoneal cavity._--I think there is little special to be said on this subject. The escape of contents into the peritoneal cavity was by no means free, unless the injury was multiple. Thus in one case of injury to the small intestine, No. 166, on which I operated, there was absolutely no gross escape until the bowel was removed from the abdominal cavity, when the contents spurted out freely. In one case of very oblique injury to the colon there was a considerable quantity of fæcal matter in a localised space, but as a rule the ordinary condition best described as 'peritoneal infection' from the wound was found. The bad effect of anything like free escape was well shown in multiple perforations; in these suppurative peritonitis rapidly developed and the patients died at the end of thirty-six hours or less. A typical case is quoted in No. 168. 2. _Peritoneal infection, and general septicæmia._--As is evident from the results quoted among the cases, the degree which this reached varied greatly. It may of course be assumed that in some measure it occurred in every case in which the bowel was perforated, but it was sometimes so slight as to be scarcely noticeable. This may be said to have been most common in injuries to the large intestine. Wounds of the cæcum, ascending and descending colon, the sigmoid flexure, or the rectum, were sometimes followed by no serious symptoms, either local or general. Again in these portions of the bowel the development of local signs, and the later formation of an abscess, were by no means uncommon. In the case of the small intestine I never observed this sequence, and the same may be said of the transverse colon, which in its anatomical arrangement and position so nearly approximates to the small bowel. In suspected wounds of these portions of the bowel either the symptoms were so slight as to render it doubtful whether a perforation had occurred, or marked signs of general peritoneal septicæmia developed, and death resulted. The condition of the peritoneum in fatal cases varied much. In some a dry peritonitis, or one in which a considerable quantity of slightly turbid fluid was effused, was found. In others a rapid suppurative process, accompanied by the effusion of large quantities of plastic lymph, was met with. My experience suggested that the latter condition was the result of free infection from multiple wounds of the gut, the former the accompaniment of single wounds. Hence I should ascribe the difference mainly to the extent of the primary infection. This is perhaps a suitable place to further discuss the explanation of the escape of a considerable number of the patients who received wounds of the abdomen, possibly implicating the bowel. Although this was not, I think, so common an occurrence as has been sometimes assumed, yet many examples were met with. Several reasons have been advanced. (1) Great importance has been given to the fact that many of the men were wounded while in a state of hunger, no food having been taken for twelve or more hours before the reception of the injury. In view of the well-proved fact in these, as in other intestinal injuries, that free intestinal escape does not occur, and that it is usually a mere question of infection, this explanation, in my opinion, is of small importance. It might with far more justice be pointed out that many of these wounded men were for them in the happy position of not having friends freely dosing them with brandy and water after the reception of the injury, and this was possibly an element of some importance. Some of the men did, however, drink freely, and in one case which terminated fatally a comrade gave a man wounded through the belly an immediate dose of Beecham's pills. (2) Mr. Treves has suggested that the effect of the severe trauma on the muscular coat of the bowel is to cause a cessation of peristaltic movement. This, as in the case of 'local shock' elsewhere, may no doubt be of importance, and to it should be added the simultaneous cessation of abdominal respiratory movements in the segment of the belly wall covering the injured part. The occurrence of general cessation of peristaltic movement is, however, to some extent opposed by the fact that in a certain number of the cases early passage of motions was seen just as happens in the intestinal ruptures seen in civil practice. I should be inclined to ascribe the escape from serious infection in these injuries to the same cause which accounts for their comparative insignificance in other regions--namely, the small calibre of the bullet and consequent small size of the lesion: in point of fact to the minimal nature of the primary infection. I very much doubt if any patient who had more than one complete perforation of the small intestine got well during the whole campaign. This opinion is, moreover, supported by the fact that the prognosis was so far better in cases of injury to the large than to the small intestine, in which former segment of the bowel we have the advantages of a position beyond the region in which intestinal movement is most free, the unlikelihood of multiple injury, and a drier and more solid type of fæcal contents. In the instances in which recovery followed perforating injuries without any bad signs we can only assume a minimal infection, and sufficient irritation and reaction on the part of the bowel to produce rapid adhesion between contiguous coils, and thus provisional closure. The other mode of spontaneous recovery which I saw several times take place in the injuries to the large bowel consisted in the limitation of the spread of infection by early adhesions and the development of a local abscess. The non-observance of this process in any case of injury to the small intestine raises very great doubts in my mind as to the frequent recovery of patients in whom the small intestine was perforated. INJURIES TO THE INTESTINAL TRACT 1. _Wounds of the stomach._--A considerable number of wounds in such a situation as to have possibly implicated the stomach were observed, and of these a certain number recovered spontaneously. The only two instances that came under my own observation are recorded below. It will be noted that in each the special symptoms were the classic ones of vomiting and hæmatemesis. In the first case blood was also passed per anum, and in the second the diagnosis was reinforced by the escape of stomach contents from the external wound. The second case was a surgical disappointment. No doubt the fatal issue was mainly dependent on the fact that the external wound had to be kept open to allow of the escape of the abundant discharge from the wounded liver. In the absence of the hepatic wound, however, I believe it would have been possible for this patient to have got well spontaneously, in view of the firm adhesions which had formed around the opening in the stomach, and the consequent localisation which had been effected. Another unfortunate element in this case was the comminuted fracture of the seventh costal cartilage, which maintained the patency of the aperture of exit. The latter point, however, was of doubtful importance from this aspect, as the vent provided for the gastric and biliary secretions may have been the safety-valve that had allowed localisation to develop. I believe that the secondary hæmorrhage was the main element in robbing us of a success in this case, and that this depended on the digestion of the wound by the gastric secretion. The early troubles which arose in the treatment of this patient well illustrate the difficulties by which the military surgeon is at times met; but the patient was admirably attended to and nursed by my friend Mr. Pershouse, and an orderly who was specially put on duty for the purpose. (163) Wounded at Rensburg. _Entry_ (Mauser), in ninth left intercostal space in posterior axillary line; _exit_, a transverse slit 1/2 an inch in length to left of xiphoid appendage. Patient was retiring when struck; he did not fall, but ran for about 1,000 yards, whence he was conveyed to hospital. He vomited half an hour after the injury (last meal bread and 'bully beef,' taken two hours previously), and during the evening three times again, the vomit consisting mainly 'of dark thick blood.' He was put on milk diet, and not completely starved; on the third day a large quantity of dark clotted blood was passed per rectum with the stool, and this continued for two days. Ten days after the injury the temperature was still rising to 100°, and did not become normal till the fourteenth day. The pulse averaged 80. The abdomen, meanwhile, moved fairly well, respirations 18 to 20. Some tenderness was present in the epigastrium and towards the spleen. Resonance throughout. Ordinary diet was now resumed, and beyond slight epigastric pain on deep inspiration, no further symptoms were observed, and the patient left for England at the end of the month. The spleen may have been traversed in this patient, as well as the lower margin of the right lung. (164*) Wounded at Enslin. _Entry_ (Mauser), 3/4 of an inch from the spine, opposite the eighth intercostal space; _exit_, through the seventh left costal cartilage, 1 inch from the median line. The patient was lying in the prone position when shot: he vomited blood freely, and the bowels acted three times before he was seen forty hours after the accident, each motion containing dark blood. On the commencement of the third day the patient's expression was extremely anxious, and he was suffering great pain. Pulse 96, temperature 100°. Tongue moist, occasional vomiting, bowels open yesterday. Has taken fluid nourishment since injury. The abdomen moved with respiration, but was moderately distended, especially in the line of the transverse colon; it was tympanitic on percussion, there was no dulness in the flanks, and only moderate rigidity of the wall on palpation. Frothy fluid stained with bile and fæcal in odour was escaping from the wound of exit, and the everted margins of the latter were bile-stained. A vertical incision was carried downwards from the wound for 4 inches. A rugged furrow was found on the under surface of the left lobe of the liver; the stomach was contracted and firmly adherent by recent lymph to the under surface of the liver and the diaphragm. The transverse colon was much distended. On separating the stomach a slit wound was found at the lesser curvature, immediately to the right of the oesophagus. This wound was closed with some difficulty with two tiers of sutures; the cavity was mopped out, and then irrigated with boiled water; a plug was introduced along the line of the furrow in the liver, and the lower part of the abdominal incision closed. The patient stood the operation well, and was removed to his tent; during the day, however, two thunder showers occurred during each of which water, several inches if not a foot deep, rushed through the camp. After the second flood he was removed to the operating room, the only house we had, and slept there. The pulse rose to 120, and respiration to 26, and there was pain, which was subdued by 1/3 grain of morphia, administered subcutaneously. A fair amount of urine was passed, and the bowels acted once, the motion containing blood. On the second day after operation there was some improvement; the pulse still numbered 116, and the temperature was raised to 100°, but the belly moved fairly, and pain was moderate. Abundant foul-smelling, bile-stained discharge came from the wound when the plug was removed. Rectal feeding was supplemented by small quantities of milk and soda by the mouth. The condition did not materially change, but on the fourth day it was evident that the suturing of the stomach wound had given way, and liquid food escaped readily when taken. The discharge remained bile-stained and very foul. No extension of inflammation to the general peritoneal cavity occurred, but it was evident that the patient was suffering from constitutional infection from the foul wound, the lower part of which opened up somewhat after the removal of the stitches on the seventh day. The wound was irrigated three times daily with 1-300 creolin lotion, but remained very foul. The man slowly lost strength, although escape from the stomach considerably decreased. On the tenth day a sudden severe hæmorrhage occurred, presumably from a large branch of the coeliac axis. The bleeding was readily controlled by a plug, and did not recur; but the patient rapidly sank, and died on the twelfth day after the operation, and fourteen days after reception of the injury. No _post-mortem_ examination was made. 2. _Wounds of the small intestine._--These were comparatively common, but offered little that was special either in their symptoms or the results attending them. Wounds were met with in every part of the small gut; but I saw no case in which an injury to the duodenum could be specially diagnosed. As to the symptoms which attended these injuries, it is somewhat difficult to speak with precision, and it must be left to my readers to form an opinion as to how many of the cases recounted below were really instances of perforating wounds. My own view is that in the majority of the cases that got well spontaneously, the injury was not of a perforating nature, and that for reasons which have been already set forth. It will, however, be at once noted that in all the five cases in which the injury was certainly diagnosed in hospital death occurred. The cases of injury to the small intestine are perhaps best arranged in three classes. 1. Those who died upon the field, or shortly after removal from it. In these the external wounds were often large, the omentum was not rarely prolapsed, and escape of fæces sometimes occurred early. Shock from the severity of the lesion, and hæmorrhage, were no doubt important factors in the early lethal issue in this class. Many of the injuries were no doubt produced by bullets striking irregularly, by ricochets, by bullets of the expanding forms, or by bullets of large calibre. As being beyond the bounds of surgical aid, this class possessed the least interest. 2. Cases brought into the Field, or even the Stationary hospitals, with symptoms of moderate severity, or even of an insignificant character, in which evidence of septic peritonitis suddenly developed and death ensued. 3. Cases in which the position of the wounds raised the possibility of injury to the intestine, but in which the symptoms were slight or of moderate severity, and which recovered spontaneously. The whole crux in diagnosis lay in the attempt to separate the two latter classes, and, personally, I must own to having been no nearer a position of being able to form an opinion on this point, in the late than in the early stage of my stay in South Africa. The advent of peritoneal septicæmia was in many instances the only determining moment. On this matter I can only add that, in civil practice, an exploratory abdominal section is often the only means of determination of a rupture of the bowel wall. With regard to the cases of suspected injury to the bowel which recovered spontaneously, the symptoms were somewhat special in their comparative slightness, and in the limited nature of the local signs. Thus the pulse seldom rose to as much as 100 in rate, 80 was a common average. Respiration was never greatly quickened, 24 was a common rate. The temperature rarely exceeded 100°. Vomiting was occasionally severe, but usually not persistent, ceasing on the second day. A good quantity of urine was passed. As to the local signs, these again were of a limited nature; distension did not occur, or was slight; movement of the abdominal wall was only restricted in the neighbourhood of the wound, the affected area amounted to a quarter, or at most half, the abdominal wall, and rigidity was localised to a similar segment. Local tenderness usually existed; but, as a rule, there was little or no dulness to point to the occurrence either of fluid effusion or a considerable deposition of lymph. Again many of the patients suffered with very slight symptoms of constitutional shock, although there was considerable variation in this particular. (165*) Wounded at Graspan, sustaining a compound fracture of the fibula. While being carried off the field, a second bullet (Lee-Metford) entered immediately outside the left posterior superior iliac spine, perforated the pelvis, and emerged 1-1/2 inch within the left anterior superior spine. The patient was then put down and left on the field ten hours; later he was carried to shelter for the night, and arrived at Orange River on the second day. He suffered with some pain in the abdomen, especially during the journey in the train, but was not sick; the bowels were confined. When seen on the third day at 6 P.M., some pain was complained of in the abdomen, which moved freely in the upper part, but was motionless below the umbilicus. No distension. Tenderness around wound of exit and some rigidity. The bowels had acted four times during the day; motions loose, dark brown, and containing no blood. Face not anxious, eyes bright, temperature 102°. Pulse 96, regular, and of good strength. Tongue moist and little furred. The abdomen was opened at 5 A.M. on the fourth day, as the local signs had become more pronounced, and the patient had passed a restless night in great abdominal pain. A local incision was chosen, as the wound was presumably in the sigmoid flexure. The sigmoid flexure was adherent to the abdominal wall opposite the wound of exit, and a dark ecchymosed patch was found, but no perforation could be detected. Foul pus and gas escaped freely from the pelvis, but no wound of the large bowel could be discovered here. On enlarging the incision upwards three openings were found in a coil of jejunum, probably that about five feet from the duodenal junction usually provided with the longest mesentery. No fourth opening could be found. The openings were circular, about 1/3 inch in diameter, clean cut, with a ring of everted mucous membrane, and the wall of the bowel in the neighbourhood was thickened. All three openings were included within a length of 2-1/2 inches. There was no surrounding ecchymosis of the bowel wall. Very little escaped intestinal contents were found in the situation of the bowel. The latter had apparently been retracted upwards, and lay to the left of the lumbar spine. The wounds were readily closed by five Lembert's sutures, three crossing the openings, and one at each end. The belly was then washed out with boiled water and closed. The delay in finding the wounds due to the mistaken impression that they would be found in the pelvis materially prolonged the operation, which lasted an hour and a half. The patient never rallied, and died seventeen hours later. It is possible that a wound in the sigmoid flexure was present which had already closed at the time of operation. (166*) Wounded at Magersfontein. _Entry_ (Mauser), opposite central point of left ilium; _exit_, 1-1/2 inch above the centre of the right Poupart's ligament. Vomiting commenced soon after the injury, and this was continuous until the patient's arrival in the Stationary hospital on the fourth day, when the condition was as follows:-- Face extremely anxious in expression. Temperature 101°, sweating freely. Pulse 110, fair strength. Tongue moist. Abdomen much distended, rigid, motionless, tympanitic throughout. Bowels confined. No urine had been passed for twenty-four hours, [Symbol: ounce]ij in bladder on catheterisation, clear, and containing no blood. Abdominal section. Median incision. A considerable quantity of bloody effusion was evacuated. Intestine generally congested and distended. No lymph. Two wounds were found in the ileum on the opposite sides of one coil; the openings were circular, with the mucous membrane everted. No escape of fæcal matter was visible until the intestine was delivered, when intestinal contents spurted freely across the room. The openings were sutured with five Lembert's stitches. The bowel was punctured in two places to relieve distension, and then returned into the belly, after washing with boiled water. Four pints of saline solution were infused into the median basilic vein, and 1/30 grain strychnine sulph. was injected hypodermically. The patient did not rally, and died twelve hours after the operation. (167*) Wounded at Graspan. _Entry_ (Lee-Metford), midway between the umbilicus and pubes; _exit_, 1 inch to the left of the fifth lumbar spine. The patient was seen on the third day in the following condition: in great pain, expression extremely anxious, vomiting constantly. Pulse 150 running, respirations 48. Temperature 100°, sweating freely. Great distension, rigidity, and general tenderness of immobile abdomen. No improvement followed the administration of brandy and hypodermic injection of strychnine 1/30 grain, and operation was deemed hopeless. In the evening the patient was apparently dying. Face blue and sunken and covered with sweat, eyes dull, speechless, pulse imperceptible, restlessness extreme, bowels acting involuntarily, no urine in bladder. The man was placed in a tent by himself, and to my surprise was alive and better the next morning; the expression was still anxious, but the face brighter and not sweating; the pulse only numbered 100, but was very weak, and the hands and feet were cold. The condition of the abdomen was unaltered, but the thoracic respiration had decreased in rapidity from 48 to 28. His condition still seemed to preclude any chance of successful intervention, but none the less life was retained until the morning of the seventh day, the state alternating between a moribund one and one of slight improvement. He was lucid at times, although for the most part wandering, and was so restless that no covering could be kept upon him. Vomiting was continuous, so that no nourishment could be retained; the bowels acted frequently involuntarily, and little or no urine was passed. Meanwhile, the abdomen became flat, then sunken, an area of induration and tenderness about 6 inches in diameter developing around the wound of entry. Slight variations in the pulse, and from normal to subnormal in the temperature, were noted, and death eventually occurred from septicæmia and inanition. (168*) Wounded at Driefontein. _Entry_ (Mauser), above the posterior third of the left iliac crest, at the margin of the last lumbar transverse process (probably through ilio-lumbar ligament); _exit_, 1 inch below and to the left of the umbilicus. The patient was wounded at 3 P.M., but not brought into the Field hospital until 9 P.M., when the temperature of the tents was below 28°F. He was considerably collapsed, suffering much pain, and vomited freely. The abdomen was flat, but very tender. Bowels confined. The column had to move at 5 A.M. the next morning, when the temperature was still near freezing, and during the day continuous fighting prevented any chance of operation. The man steadily sank during the day, and died thirty-six hours after the reception of the injury. _Post-mortem condition._--Belly not distended, dull anteriorly in patches, and right flank dull throughout. When the belly was opened, extensive adhesion of omentum and intestine enclosing numerous collections of pus were disclosed, and on disturbing the adhesions a large collection of turbid blood-stained fluid was set free from the right loin. The great omentum was much thickened and matted, with deposition of thick patches of lymph; very firm recent adhesions also united numerous coils of small intestine. The pus was foetid, but no appreciable quantity of intestinal contents was detected in it. The lower half or more of the small intestine was injected, reddened, and thickened. The wounds which were situated in the lower part of the jejunum and ileum were multiple, and seven perforations were detected; besides these the intestine was marked by bruises, and some gutter slits affecting the serous and muscular coats only. Considerable ecchymosis surrounded these latter. The clean perforations were circular, less than 1/4 inch in diameter, and for the most part closed by eversion of the mucous membrane. Intestinal contents were not apparent, but escaped freely on manipulation of the bowel. (169*) Wounded at Magersfontein. _Entry_ (Mauser), over the eighth rib in the anterior axillary line; _exit_, 1 inch to the left of second lumbar spinous process, just below the last rib. Vomiting commenced almost immediately after reception of the injury, and the bowels acted frequently. This condition persisted until the fourth day, when the patient was brought down to Orange River, and the signs were as follows. Considerable pain in left half of abdomen, pulse 110, fair strength, temperature 101°. Some general distension of abdomen with complete disappearance of hepatic dulness. Some movement of right half of abdomen, left half immobile, dulness extending from the flank as far forwards as linea semilunaris. An incision was made in left linea semilunaris, and Oj blood evacuated from the left loin. There was no lymph on the intestines nor sign of inflammation. No perforation was discovered in either stomach or intestine, but on two coils of jejunum there were deep slits 3/4 inch long, extending through both peritoneal and muscular coats. Beyond these wounds, on other coils oval patches of ecchymosis, due to direct bruising, were present. The peritoneal cavity was sponged free of all blood and irrigated with boiled water; no bleeding point was discovered, and the abdomen was closed. The next morning the patient was comfortable; temperature 100.2°, pulse 100. Tongue clean and moist; he vomited once during the night. Some bloody discharge had collected in the dressing, and at the lower angle of wound there was a local swelling, apparently in the abdominal wall. The flank was resonant. During the afternoon the patient became faint, and when seen at 6 P.M. was in a state of collapse, in which he shortly died. Death was apparently due to renewal of the previous hæmorrhage. No _post-mortem_ examination was made. (170*) Wounded at Magersfontein. _Entry_ (Mauser), 1/2 inch to the left of the second sacral spine; _exit_, immediately below the left anterior superior iliac spine; the patient was kneeling at the time, and the same bullet traversed his left thigh in the lower third. When seen on the third day, the lower part of the abdomen was motionless, tumid, and tender. The bowels had been confined for three days; there had been no sickness, and the tongue was moist and clean. Temperature 100°, pulse 90, fair strength, respirations 38. The patient had once had an attack of acute appendicitis, and he himself said he was sure he now had 'peritonitis,' as he had pain exactly similar in the belly to that he had suffered in his previous illness. No further signs, however, developed under an expectant treatment, and he remained some two months in hospital, while the wound in the thigh and a third injury to the elbow-joint were healing. (171) _Entry_ (Mauser), at the highest point of the left crista ilii; _exit_, through the right ilium, 2 inches horizontally anterior to the posterior superior spine. Absolutely no abdominal symptoms followed. The bowels were confined five days, and then opened by enema. The patient complained of some stiffness in the lumbo-sacral region, but the right synchondrosis was no doubt implicated in the track. (172) Wounded at Paardeberg (range 800 yards). _Entry_ (Mauser), 2 inches diagonally below and to the right of the umbilicus; _exit_, not discoverable. For the first two days the patient had to lie out with the regiment; on the fourth he was removed to the Field hospital. During the first three days the patient vomited (green matter) frequently, and the belly was hard and painful; as biscuit was the only available food, no nourishment was taken. The bowels acted on the second night. At the end of a week the patient was sent by bullock wagon (three days and nights) to Modder River, and then down to Capetown, where he walked into the hospital on the thirteenth day, apparently well. Two days later the temperature rose to 104°, and enteric fever was diagnosed, no local signs pointing to the injury existing. The patient made a good recovery. (173) Wounded at Colenso. _Entry_ (Mauser), at junction of outer 2/5 with inner 3/5 of line from right anterior superior iliac spine to umbilicus; _exit_, at upper part of right great sacro-sciatic foramen, in line of posterior superior iliac spine. Advancing on foot when struck; he then fell and crept fifty yards to behind a rock, where he remained seven and a half hours. For two days subsequently he vomited freely; the bowels acted nine hours after the injury, and then became constipated. No further symptoms were noted, and at the end of three weeks the abdomen was absolutely normal. The man is now again on active service. (174*) Wounded at Modder River while retiring on foot. _Entry_ (Mauser), at highest point of right iliac crest; _exit_, 2-1/2 inches to right of and 1/2 inch above level of umbilicus. The injury was not followed by sickness, and the bowels remained confined. During the first two days 'pain struck across the abdomen' when micturition was performed. When the patient came under observation on the third day the condition was as follows:--Complains of little pain, temperature normal, pulse 72, respirations 24, tongue moist, bowels confined. Rigidity of abdominal wall and deficient mobility of nearly whole right half of belly, the whole lower half of which moves little with respiration. No track palpable in abdominal parietes. No dulness, no distension. The temperature rose to 99.5° at night. On the fourth day the bowels acted freely, the pulse fell to 60, the respirations were 24, and the temperature normal. Tenderness and rigidity persisted in the right flank to the end of a week, after which time no further signs persisted. (175*) Wounded at Modder River while lying on right side. Range 500 yards. Walked 400 yards after injury. _Entry_ (Mauser), at the junction of the posterior and middle thirds of the right iliac crest; _exit_, 3 inches to right of and 1/2 inch below the level of the umbilicus. The injury was followed by no signs of intra-abdominal lesion; on the third day the temperature was normal, pulse 80, and the tongue clean and moist. Some soreness at times and tenderness on pressure were complained of, but the man was discharged well at the end of one month. (176*) Wounded while doubling in retirement at Modder River. _Entry_ (Mauser), immediately above the junction of the posterior and middle thirds of the left iliac crest; _exit_, 1 inch below costal margin (eighth rib), 3 inches to the right of the median line. The bullet was lying in the anterior wound, whence it was removed by the orderly who applied the first dressing on the field. The patient remained on the field seven and a half hours, and when brought into hospital at once commenced to vomit. The ejected matter, at first green in colour, during the next forty-eight hours changed to a dirty brown. Meanwhile, the abdomen was somewhat painful. When seen on the third day he had ceased to vomit for three hours. The face was slightly anxious, and the patient lay on the ground with the lower extremities extended. Temperature 99°, pulse 72, fair strength. Respirations 32, shallow. Tongue moist, lightly furred, bowels not open for four days. He slept fairly last night. Abdomen soft, moving well with respiration, no distension, slight tenderness below and to the right of the umbilicus, and local dulness in right flank. The next day the pulse fell to 60 and the bowels acted, but there was no change in the local condition. The man looked somewhat ill until the end of a week, but was then sent to the Base, and at the expiration of a month was sent home well. (177*) Wounded at Modder River. Two apertures of _entry_ (Mauser); (_a_) below cartilage of eighth rib in left nipple line; (_b_) 2 inches below and 4-1/2 inches to the left of the median line. No exit wound discovered, and no track could be palpated between the two openings, which were both circular and depressed. When seen on fourth day there was tenderness in the lower half of the abdomen, and the left thigh was held in a flexed position. Respirations 20, respiratory movement confined to upper half of abdominal wall. Pulse 70, temperature 99°. Tongue moist, covered with white fur; bowels confined since the accident; no sickness. The patient remained under observation thirteen days, during which time pain and difficulty in movement of the left thigh persisted, also slight tenderness in the lower part of the abdomen; but at the end of a month he was sent to England well, but unfit to take further part in the campaign. I thought the bullet might be in the left psoas, but it was not localised. (178*) Wounded at Modder River. _Entry_ (Mauser), 3-1/2 inches above and 1-1/2 inch within the left anterior superior iliac spine; _exit_, 1-1/2 inch to the right of the tenth dorsal spinous process. The same bullet had perforated the forearm just above the wrist prior to entering the abdomen. No local or constitutional signs indicated either bowel injury or perforation of liver. The man, however, was suffering from a slight attack of dysentery, passing blood and mucus per rectum with great tenesmus. He was sent to the Base at the end of a week, and returned to England well three weeks later. He attributed his dysentery to the wound, as the symptoms did not exist prior to its reception; but as the disease coincided exactly with what was very prevalent amongst the troops at the time, I do not think there was any connection between it and the injury. (179) Wounded near Thaba-nchu. _Entry_, over the centre of the sacrum at the upper border of fourth segment; _exit_, 1-1/2 inch above left Poupart's ligament, 2 inches from the median line. Aperture of entry oval, with long vertical axis. Exit wound a transverse slit, with slight tendency to starring (see fig. 19, p. 58). One hour after being shot the patient vomited once. There was some evidence of shock and considerable pain. The bowels acted involuntarily simultaneously with the vomiting, and incontinence of fæces and retention of urine persisted for four days. The vomit was bilious in appearance; no blood was seen either in it or the motions. Forty-six hours after the injury the condition was as follows: Face slightly anxious and pale; skin moist, temperature 100.4°; pulse 116, regular and of fair strength; respirations 24; abdomen slightly tumid; tenderness over lower half, especially on left side; the lower half moves little with respiration. Twenty-four hours later the patient had improved. He was comfortable and hopeful; slept well with morphia 1/3 grain hypodermically. Tongue moist, covered with white fur; has been taking milk only, [Symbol: ounce]ij every half-hour. No sickness. Temperature 99°. Pulse 104. Respirations 24. Abdomen flatter; general respiratory movement; tenderness now mainly localised to an area 2-1/2 inches in diameter, to the left of the umbilicus, above exit wound. The patient continued to improve, and on the fifth day travelled six hours in a bullock wagon to Bloemfontein. Soon after arrival his temperature was normal: pulse 80, respirations 16, with good abdominal movement. Local tenderness persisted in the same area, but was less in degree. Tongue rather dry, bowels confined. Micturition normal. Two drachms of castor oil and an enema were given. On the ninth day patient was practically well, except for slight deep tenderness. He remained in bed on ordinary light diet, but at the end of the third week he was seized by a sudden attack of pain, the temperature rising to 103° and the pulse to 140, the abdomen becoming swollen and tender. He was then under the charge of Mr. Bowlby, who ordered some opium, and the symptoms rapidly subsided. Although this wound crossed the small intestine area, it is probable that the symptoms may have been due to an injury of the rectum or sigmoid flexure. 3. _Wounds of the large intestine._--Injuries to every part of the large bowel were observed, and spontaneous recoveries were seen in all parts except the transverse colon, which, as already remarked, is near akin to the small intestine with regard to its position and anatomical arrangement. The only case of perforation of the vermiform appendix that I heard of, one under the care of Mr. Stonham, died of peritoneal septicæmia. Several cases of recovery from wounds of the cæcum and ascending colon are recounted below. The only points of importance in the nature of the signs of these injuries were their primary insignificance, and the comparative frequency with which _local_ peritoneal suppuration followed them. The absence of a similar sequence in some of the cases in which wounds of the small intestine were assumed, was, in my opinion, one of the strongest reasons for doubting the correctness of the diagnosis. It is also a significant fact that injuries of the ascending colon--that is to say, of the portion of the large bowel which perhaps lies most free from the area occupied by the small intestine--were those which most frequently recovered. The following cases afford examples of the course followed in a number of injuries to the large intestine, and illustrate both the uncomplicated and the complicated modes of spontaneous recovery. No. 180 affords a good example of an extra-peritoneal injury, and of the especially fatal character of such lesions. This case was also one of my surgical disappointments. Nos. 182, 183 are of great interest in several particulars. First, the aperture of exit was large and allowed the escape of fæces, not a very common feature in wounds not proving immediately fatal. Secondly, in neither were any peritoneal signs observed. Thirdly, in each the exit wound communicated with the pleura, and the patients died from septicæmia mainly due to absorption from the surface of that membrane (_Pleural septicæmia_). No. 190 is a most striking instance of spontaneous cure, since no doubt can exist that both rectum and bladder were perforated. (180*) _Injury to the cæcum and ascending colon._--Boer, wounded at Graspan while sheltering behind a rock, lying on his back. _Entry_ (Lee-Metford), in right thigh, 3 inches below and 1 inch within anterior superior spine of ilium; _exit_, in back, on a level with the fourth lumbar spinous process and 3 inches from that point. Half an hour after the wound the patient commenced to suffer severe stabbing pain; he lay on the field one hour; later he was taken to a Field hospital, and on the second day was sent by train a distance of twenty-five miles. When seen at the end of fifty hours the condition was as follows. Face anxious, complexion dusky. Great abdominal pain, especially about the umbilicus. Vomiting frequent and distressing; bowels confined since the accident; tongue dry and furred. Urine scanty. Pulse full and strong, 125; respirations, entirely thoracic, 30. Abdomen generally distended and tympanitic, wall rigid and motionless. Dulness in right flank, together with superficial oedema and emphysema. Abdominal section fifty-three and a half hours after accident. Incision in right linea semilunaris. Great omentum adherent to ascending colon, which was covered with plastic lymph. Gas and intestinal contents escaped from an opening at the line of reflexion of the peritoneum from the ascending colon; retro-peritoneal extravasation and emphysema extended the whole length of the ascending colon and around duodenum, the wall of the colon itself exhibiting subperitoneal emphysema. The colon was freed and the rent sewn up with interrupted sutures. About [Symbol: ounce] iv of foul fæcal fluid were evacuated from loin, and a free counter-opening made. The opening in the ilium by which the bullet had entered the abdomen was found at the brim of the pelvis; the loin and peritoneal cavity were sponged dry and flushed with boiled water; no lymph was seen on the small intestine. A large gauze plug was inserted into the posterior wound, one end of the plug being brought out of the operation incision. During the succeeding six days progress was not unsatisfactory: the abdomen became soft, moved with respiration, there was no sickness, and the bowels acted. The pulse fell to 90, respirations to 20, and the temperature did not exceed 102° F. The wound suppurated freely, however, and although there were no further signs of peritoneal septicæmia, it was evident that general infection had taken place, and on the sixth day a parotid bubo developed on the right side, which was opened. On the seventh day the patient suddenly commenced to fail rapidly; vomiting was almost continuous--at first curdled milk, later frothy watery fluid--and on the eighth day he died. The abdomen remained soft, sunken, and flaccid, and death no doubt resulted from general septicæmia rather than from peritoneal infection, absorption taking place from the large foul cavity behind the colon. As the cavity in part surrounded the descending duodenum, this possibly accounted for the attack of vomiting which preceded death. (181*) _Ascending colon._--Wounded at Graspan while lying in prone position. _Entry_ (Mauser), over ninth rib in line of right linea semilunaris; _exit_, in right buttock, just below and behind the top of the great trochanter. The injury was followed by little abdominal pain, but a strange sensation of local gurgling was noted. The bowels acted as soon as the patient reached camp, some hours after being wounded. There was no sickness and nothing abnormal was noted in the motions, except that they were loose and light-coloured. On the evening of the third day the patient came under observation in the ambulance train for Capetown. He looked somewhat anxious and ill, but he complained of little pain; the temperature was 102°, pulse 88, fair strength, soft and regular. There was local dulness, tenderness, and deficiency of movement in the right iliac region. As it was night, he was removed from the train and an operation was performed the next morning. Prior to operation the condition was as follows: Pulse 84, temperature 100°; respiration easy, 20. Tongue moist, but thickly coated in centre. Abdomen moves fairly, and is resonant, except in right lower quadrant. No distension. Dulness, tenderness, and rigidity in right iliac region, marked to outer side of cæcum. Entry wound nearly and exit quite healed. Cannot flex right thigh. The following operation was performed. Appendix incision, about [Symbol: ounce]j of fæcal fluid and fæces in a localised cavity on outer and anterior aspect of cæcum evacuated; adhesions very firm. Cavity sloughy throughout and cæcum covered with dull grey lymph. The opening in the bowel was not localised, and it was considered wiser to treat the case like one of perforation from appendicitis than to run the risk of breaking down adhesions. A small awl-like opening was found in the ilium with powdered bone at its entrance leading to the wound of exit. The after-treatment of the case gave rise to no anxiety, but healing of the resulting sinus was slow; fæcal-smelling pus escaped for some days, and a number of small sloughs came away. On the twelfth day the patient was sent down to Wynberg, where he remained twelve weeks. A counter-incision was needed in the loin to drain the suppurating cavity three weeks after the primary operation, and five weeks after the operation an escape of gas and fæces took place from the anterior wound, while the bowels were acting, as a result of a dose of castor oil. No further escape of fæces occurred, and he left for England with a small sinus only. No extension of inflammation into the original wound track ever occurred, both openings and the canal healing by primary union. The sinus remained open, and occasionally discharged for a further period of six months, and then healed firmly; since when the patient has been in perfect health. (182*) _Splenic flexure, descending colon._--Wounded at Magersfontein. _Entry_ (Mauser), in sixth left intercostal space in mid-axillary line; _exit_, in left loin, below last rib, at outer margin of erector spinæ. The patient remained in the Field hospital three days, during which time he exhibited no serious abdominal symptoms, but during the journey to Orange River (53-1/2 miles) he was sick. He remained at Orange River two days, and while there an enema was administered, producing a normal motion. The abdomen was slightly distended; it moved fairly, there was slight rigidity, but little tenderness. Temperature 100.8°, pulse 120. No appearance of fæces in wound. When seen on the sixth day the condition was as follows:--Patient cheerful and not in great pain. Temperature 99.2°; pulse 120; respirations 48, very shallow. Abdomen soft, moving freely, no distension or general tenderness. Fluid fæces escaping in abundance from the wound in loin. Redness of skin and swelling below level of wound, and cellular emphysema above. Fæcal-smelling fluid was also escaping from the thoracic wound. The wound was enlarged, but the patient rapidly sank, and died of septicæmia on the seventh day. (183*) An exactly similar case came under observation from the battle of Modder River, except that the opening in the loin was somewhat larger, and earlier and freer escape of fæces took place from it. In this also fæcal matter passed freely into the left pleural cavity, and fæcal matter was expectorated, while there was an almost complete absence of abdominal symptoms. Death occurred on the fourth day. No _post-mortem_ examination was made in either case, but I believe in both the extra-peritoneal aspect of the colon was implicated and that the septicæmia was in great part due to absorption from the pleural rather than the peritoneal cavity, since in neither case were the abdominal symptoms a prominent feature. (184) _Possible wound of cæcum._--Wounded at Spion Kop. Bullet (Mauser) perforated the right forearm, then entered belly. _Entry_, 3 inches from the right anterior superior iliac spine, in the line of the supra-pubic fold of the belly wall (a transverse slit); _exit_, in right buttock, on a level with the tip of the great trochanter and 2 inches within it. The wound was received immediately after breakfast had been eaten. There was retention of urine and constipation for three days, but no sickness. Local pain and tenderness were severe, and at the end of three weeks there was still local tenderness, slight induration, and dragging pain on defæcation. The patient returned to England at the end of a month well, except for slight local tenderness. (185) _Possible wound of colon._--Wounded at Paardeberg; range 200 yards. Walking at time. The bullet (Mauser) perforated the left forearm, just below the elbow-joint. _Entry_, into belly 1 inch anterior to the tip of the left eleventh costal cartilage; no exit. The injury was followed by pain in the left half of the abdomen and vomiting, which continued for two days. The bowels acted on the third day; no nourishment was taken for two days, but a small quantity of water was allowed. No further symptoms were noted, and at the end of a fortnight the patient was well, except for slight local tenderness. The bullet could not be detected with the X-rays. (186) _Wound of cæcum_.--Wounded at Paardeberg. _Entry_ (Mauser), 2 inches diagonally above and within right anterior superior iliac spine; _exit_, immediately to the right of the fifth lumbar spinous process; the patient was lying on his left side when struck. A burning pain down the right thigh immediately followed the accident, and lasted some days. There was no sickness, the bowels were confined three days, and there was pain across the back and down the thigh. On the tenth day he arrived at the Base, when he was lying on his back suffering considerable pain. The temperature ranged to 101°. There was diarrhoea and cystitis, with a considerable amount of pus in the urine, which was very offensive. A small fluctuating spot existed on the back, just to the right of the original exit wound which was firmly healed. The abdomen moved fairly with respiration in its upper part, but was motionless below, especially in the right iliac fossa; some induration was to be felt here. The right thigh was kept flexed. During the next few days the pus disappeared from the urine, and with this change the induration in the right iliac fossa increased. An incision (Mr. Gairdner) was made into the fluctuating spot behind, and pus evacuated. The patient recovered. (187) _Possible wound of cæcum._--Wounded outside Heilbron. _Entry_ (Mauser), in the right loin, 2-1/2 inches above the iliac crest, at the margin of the erector spinæ; _exit_, 1-1/2 inch above and within the right anterior superior spine of the ilium. There was little shock. The patient was brought six miles in a wagon into camp, and slept comfortably with a small morphia injection. Prior to the accident the patient was suffering from diarrhoea, but afterwards the bowels were confined. The next morning there had been no sickness and little pain. The tongue was moist and clean, the pulse 80, the respirations 24, the belly moved generally, although inspiration was shallow; the temperature was 99°. Slight tenderness in the belly to the inner side of the exit wound, but no dulness. The patient was starved for the first thirty-six hours, a little warm water then being allowed. No symptoms developed, and a perfect recovery followed. (188) _Colon_, _liver_.--Wounded outside Heilbron. _Entry_ (Mauser), midway between the last right rib and the crista ilii; _exit_, below the eighth costal cartilage in nipple line. There were no serious primary symptoms, but ten days after the accident the temperature rose, swelling and pain developed in the right loin, and on the fourteenth day a large tympanitic abscess was opened (Dr. Flockemann, German Ambulance.) Fæcal-smelling gas and pus were evacuated. There was no extension of the abscess forwards. A week later the patient had much improved, although there were evident signs of general absorption, and the discharge from the abscess cavity was abundant and very foul. On the thirteenth day a serious hæmorrhage occurred from the loin wound, which was opened up, but no evident source was discovered; hæmorrhage was repeated the next day, and the man died. At the _post-mortem_ examination a large quantity of chocolate-coloured fluid was found free in the abdomen and pelvis. A chain of small local abscesses was found surrounding the ascending colon, and a larger one over the front of the cæcum. The wall of the ascending colon was generally thickened, and from this, in three places, openings with rounded margins connected the abscess cavities with the lumen of the bowel. One of the openings, larger than the others, was possibly the aperture of entry of the bullet; the others were apparently spontaneous. At the anterior border of the right lobe of the liver an abscess cavity existed in connection with the wound of the liver, and this was continuous with the aperture of exit, although not discharging. The aperture of exit was plugged by a tag of omentum (see fig. 89). No obvious source of the hæmorrhage was forthcoming, but it probably originated in one of the large branches of the vena cava. The bullet had struck the transverse process of the lumbar vertebra, but had not given rise to any signs of spinal concussion. (189*) _Ascending colon._--Wounded at Modder River. _Entry_ (Mauser), midway between the tip of the tenth right rib and the iliac crest. Bullet retained. A second wound existed over the centre of the left sterno-mastoid, and the bullet here was also retained and never localised. The patient stated that he brought up blood at short intervals for half an hour immediately after he was wounded. This might have been explained by the wound in the neck, but no difficulty in swallowing was noted. The bowels acted the day after he was shot, and, except for some local tenderness and immobility, no abdominal signs were noted. Three weeks later a swelling was obvious to the right side of the umbilicus, and a tympanitic abscess developed; this was opened, and a deformed Mauser bullet extracted. Foul pus, but no fæcal matter, was evacuated, and after discharging for a fortnight the wound closed, and the man was sent home as 'well.' In this case I assumed a wound of the ascending colon had occurred. (190*) _Rectum and bladder._--Wounded at Graspan, while retiring at the double. _Entry_ (Mauser), 1 inch to the right of the coccyx; _exit_, 1 inch above the junction of the middle and outer thirds of left Poupart's ligament. The man suffered with some pain in the abdomen, and for first two days with retention of urine. The urine was drawn off with the catheter, and contained blood. During the next five days micturition was hourly or more frequent; gas was passed _per urethram_, and the urine was very foul, containing evident fæcal matter. Micturition continued frequent, with purulent cystitis for one month. Local tenderness, pain, and immobility developed over the lower quarter of the abdomen, extending to the right iliac fossa. A local abscess pointed a little to the right of the mid line, and 2 inches above the symphysis, and from this foul-smelling pus, but no fæces, was discharged for three months, during which period the surrounding dulness and induration gradually decreased and the sinus healed. When the patient left for England there was still occasional slight discharge from the original wound of entry, and there was slight discomfort on micturition, but he was otherwise well. A year later the man had resumed active duty, and, except for occasional pain on stooping, considered himself well. The following cases are appended as of some general interest. The first two (191, 192) illustrate extra-peritoneal injuries to the rectum. In neither did positive evidence exist of wound of the bowel, but the symptoms in each rendered this accident probable. Case 193 is an illustration of apparent escape of the anal canal in a wound in which from the position of the external apertures this escape would have appeared impossible. Wounds of the extra-peritoneal portion of the rectum, as a rule, appeared to have a somewhat better prognosis than would have been expected; in any case, the prognosis was far better than that obtaining in wounds of the base of the urinary bladder. My experience on the subject of these wounds was, however, limited to the two cases quoted. Case 194 is inserted as an example of the complicated nature of the abdominal injuries not so very unfrequently met with. It illustrates well the difficulty which may arise at any stage in the course of treatment of an injury, in the certain determination or exclusion of wound of a part of the alimentary canal. (191) Wounded at Magersfontein. _Entry_ (Mauser), in the right loin, immediately below the ribs in the mid-axillary line; _exit_, about the centre of the left buttock, on a level with the tip of the great trochanter. A second lacerated shell wound of back was present. All the wounds suppurated. For the first sixteen days following the injury all control was lost over the anal sphincter, and bloody fæces, and later slime, constantly escaped, but no fæcal matter ever escaped from the wound in the buttock. There was no history of previous dysentery, and rectal examination afforded no information. The buttock wound had to be opened up, disclosing a tunnel in the ilium. The wounds granulated slowly with continuous suppuration, but were healed, and the patient returned home at the end of fourteen weeks, the bowels acting normally. (192) Wounded at Paardeberg. _Entry_ (Mauser), at the junction of the middle and posterior thirds of the left iliac crest; the bullet was retained, and removed (Mr. Pegg) from the back of the right thigh, 3 inches below the back of the great trochanter. After the injury retention of urine followed, with incapacity to control loose motions, though solid ones could be retained. The retention was treated by catheterisation, which was followed by cystitis. The power of micturition was slowly recovered, and three weeks later he could pass water, at times in a dribbling stream only; the cystitis had improved. The man returned to England very much improved, but not quite well, at the end of five weeks. (193) Wounded at Modder River. _Entry_, in the right buttock, near the outer border at the upper part; _exit_, at the lower part of outer border of left buttock. The line of the wound exactly crossed the position of the anus, but no sign of injury to the rectum could be discovered. (194) Wounded at Magersfontein. _Entry_ (Mauser), 1/2 inch below the margin of the iliac crest, at the junction of its middle and posterior thirds, and on a level with the fifth lumbar spinous process; _exit_, below the cartilage of the eighth rib, just within the left nipple line. Struck while retiring; fell at once, and remained thirty hours on the field. Patient stated that he vomited 'blood like coffee grounds' six times while lying on the field, and twice after being brought in. His bowels were confined for three days. His right lower extremity was paralysed. On the fifth day there was considerable induration around the wound of exit, and the upper half of the abdomen was immobile and tender. The temperature rose to 100°, and the pulse was 96. Shortly afterwards a similar condition was noted in the lower half of the abdomen; the temperature continued to be raised and the pulse quickened, when on the thirteenth day a considerable quantity of pus was passed per rectum, and diarrhoea set in; this continued for three days, with marked improvement in the general symptoms. Micturition, which had been painful, became normal; the pulse and temperature fell, and the expression became less anxious. The patient continued to sleep badly, however, and complained of pain. At the end of the third week he still looked ill, but was easier. Temperature normal in the morning, 100° in evening, pulse 80. Tongue thickly furred, but moist. Still on milk diet; appetite bad; bowels irregular. The abdomen moved little in the lower half, induration persisted in the left iliac fossa, the left thigh continued flexed, and resonance was impaired to the left of the umbilicus. At the end of six weeks a distinct hard swelling in two parts, separated by a resonant area, was noted to the left of the umbilicus and in the left iliac fossa. The abdomen moved fairly, and there was little tenderness over the swelling. During the next week the swelling appeared to increase and to fluctuate; at the same time the temperature again began to rise to 100° and 101° at eve. The swelling was taken to be a localised peritoneal suppuration, and an incision was made over it; but this led down to a free peritoneal cavity, with a tumour pressing up from the posterior abdominal wall. The wound was therefore closed, and a fresh extra-peritoneal incision made, immediately above Poupart's ligament, when the swelling proved to be a large retro-peritoneal hæmatoma. As the cavity extended into the pelvis and up to the level of the costal margin, it was deemed wise only to evacuate a part of the blood-clot. The origin of the bleeding was not determined, and the wound was closed and healed by first intention. The man continued to improve, and left for home five weeks later. This patient has continued to improve since his return, but the left thigh is still somewhat flexed. _Prognosis in intestinal injuries._--This was of a most discouraging character compared with the prognosis in abdominal injuries as a whole. The cases were of two classes, however: those that died within twenty-four hours, and those that died at the end of from three days to a week. Cases falling into the first category are obviously of little importance from the point of view of surgical treatment. Many of them died from the widespread nature of the injury, and the shock produced by it; others from hæmorrhage from the large abdominal vessels. It is unlikely that any could have been saved, even under the most satisfactory conditions. In the following small table, therefore, I have included only the cases which have been already quoted, which survived long enough to be amenable to surgical treatment, and which were for some days under my own observation. Some of them, in fact almost all, I watched until they were either convalescent, or died, and in six I performed operations. I am aware, and have short details of the histories of eight patients wounded in the same battles who died prior to the termination of the first thirty-six hours; but these are not included, for the reason stated above, and also because I am uncertain whether all the injuries were produced by bullets of small calibre. -------------------------+-----------+-------------+-----------+------+ | | Localised | | | Viscous wounded | Number of | Secondary | Recovered | Died | | cases | suppuration | | | | | occurred | | | -------------------------+-----------+-------------+-----------+------+ Stomach certain | 2 | -- | 1 | 1 | Stomach possible | 1 | -- | 1 | -- | Small intestine certain | 5 | 0 | -- | 5 | Small intestine possible | 10 | 0 | 10 | -- | Large intestine certain | 8 | 4[21] | 4 | 4 | Large intestine possible | 4 | -- | 4 | -- | -------------------------+-----------+-------------+-----------+------+ Bladder certain | 3 | 3 | 1 | 2 | Bladder possible | 1 | -- | 1 | -- | Liver | 6 | -- | 6 | -- | Kidneys | 6 | -- | 4 | 2 | Spleen | 3 | -- | 2 | 1 | -------------------------+-----------+-------------+-----------+------+ Total | 49[22] | -- | 34 | 15 | -------------------------+-----------+-------------+-----------+------+ Included in the above table are thirty instances of intestinal injury, and these are divided up according to the segment of the intestinal canal implicated, and also as to whether the perforation was certain, or only assumed from the position of the external apertures and the presence of abdominal symptoms of a noticeable grade. From this analysis it appears clear-- 1. That wounds of the stomach have a comparatively good prognosis, and that they may recover spontaneously. It is true that only two examples are included in my table; but I was at various times shown patients with similar injuries and histories, and a number of cases which have been published appear to substantiate the opinion. From our experience of the occasional spontaneous recovery of gastric perforations from disease, I think we might be prepared to expect that the stomach would offer a comparatively favourable seat for these wounds. It may be pointed out, however, that hæmatemesis, the main feature in the symptoms pointing to wound, is by no means direct proof of more than contusion. 2. That perforating wounds of the small intestine are very fatal injuries; every patient in whom the condition was _certainly_ diagnosed died. 3. That in the cases in which a perforation was inferred from the position of the external apertures and the symptoms, not one patient suffered from the secondary complications--_e.g._ local peritonitis and suppuration, which were common in the case of the large intestine, and which we are accustomed to see after perforation from disease. This renders the occurrence of actual perforation in the majority of the cases a matter of very grave doubt. If spontaneous recovery does take place after this injury, it is only in cases in which the wounds are single, and slight in character. 4. That in eight cases in which perforation of the large intestine was certain, four recoveries took place; but in each instance suppuration occurred. I am, however, quite prepared to believe that perforation may have occurred in some or all of the other four cases included as 'possible,' provided the wounds were intra-peritoneal. Wounds of the cæcum and ascending colon are those which have the best prognosis, and after these of the rectum. The comparatively good prognosis in these parts is what would be expected, on account of their greater fixity, and lesser tendency to be covered by the small intestine. An extra-peritoneal wound of any of these portions of the bowel is more dangerous than an intra-peritoneal, and more likely to give rise to septicæmia. Of the cases included in my table eighteen of the possible intestinal injuries were observed among the wounded of the four battles of the Kimberley relief force. These cases I saw early and followed to their termination, and I believe the list contains the great majority of all the patients who received intestinal wounds in those battles. On inquiry I could not learn of others from the officers of the Field hospitals; but no doubt some patients died before their reception into hospital, and some may have been overlooked; again, I know of two cases in which death took place within the first week, but which went direct to the Base and did not come under my observation. These exceptions being made, we have a fairly complete series, from which some deductions may be drawn. The cases included are marked with an asterisk. Of the eighteen cases, eight or 44.4 per cent. died. These were made up as follows:--Stomach, one case; this patient died at the end of fourteen days, as a result of secondary hæmorrhage and septicæmia. It was complicated by a severe wound of the liver and also one of the lung. Small intestine, four certain cases; all died, two after operation in the stage of septicæmia, and one after operation from recurrent hæmorrhage, possibly from the mesentery. Of the other six cases one can only say that the position of the wounds was such as to render wound of the intestine possible, and that all suffered with abdominal symptoms of some severity. Large intestine. Of six cases in which wound was certain, three died, one after operation. One recovered after operation, two recovered with local peritoneal suppuration. In one case the injury could only be returned as possible. In connection with this subject I have received permission from Mr. Watson Cheyne to quote the statistics published by him[23] concerning the abdominal wounds observed after the fighting at Karree Siding, on March 29, which are as follows:-- 'The number of the wounded was 154, and in fifteen it was considered that the abdominal cavity had been penetrated. Of these patients, five had already died within twenty-four to twenty-eight hours after the injury, and I saw ten who were still alive. Of these nine were left alone, and four died within the next twenty-four or thirty-six hours; five were still alive when I left Karee on Sunday afternoon, April 1. On one I operated, but he died on April 2. The Karee statistics are really the only complete ones which I have as yet been able to obtain. The following are the notes of the cases above alluded to. Besides the five cases of abdominal wounds which had already died, and of which I could get no complete details, the following ten are cases which I saw from twenty-four to thirty hours after they were shot:-- CASES FROM THE ACTION AT KAREE CASE I.--The point of entrance was 2 inches to the right of the umbilicus, and the bullet was found lying under the skin far back in the left loin. The patient was pulseless, and there was much rigidity of the abdomen, tenderness, and vomiting. He died a few hours later. CASE II.--The bullet, coming from the side, had entered the abdomen 4 inches below and behind the right nipple. There was no exit wound. The patient had been vomiting a good deal, but not any blood; the abdomen was very rigid and tender. He was obviously very ill, and died the next morning. The bullet had probably perforated the liver and _stomach_. CASE III.--There was a large wound above the right anterior iliac spine (probably the point of exit), and a small opening behind and near the spine on the same side. There was great tenderness and rigidity of the abdomen. He died a few hours later. CASE IV.--In this case there was a transverse wound of the abdomen, the bullet having entered on the right side in the middle of the lumbar region and passed out on the left side, rather higher up and further back. All the symptoms of acute peritonitis were present. The patient died the next morning. CASE V.--The bullet had entered the anterior end of the sixth intercostal space on the left side, and was found lying under the skin over the seventh intercostal space on the right side and about 2 inches further back. He had vomited blood on the previous day. The bullet may have perforated the _stomach_. The epigastrium was somewhat tender, but there were no marked symptoms. On April 1 he was going on well. CASE VI.--The place of entrance of the bullet was 1 inch in front of the right anterior superior spine, and of exit behind the left sacro-iliac synchondrosis. There was much hæmorrhage at the time. His condition when I saw him was fair, and there was no marked abdominal tenderness. On April 1 his morning temperature was 101°. There were no signs of general peritonitis, and his condition was good. CASE VII.--The bullet had entered from behind, about the tip of the twelfth rib on the left side, and had left about the middle of the epigastrium, and rather to the left of the middle line. Vomiting was still going on, but not of blood. There was much tenderness and rigidity of the abdomen, and he was almost pulseless. On April 1 his general condition was better, but the abdomen was very rigid and tender. (Subsequently died.) CASE VIII.--The point of entrance of the bullet was about 2 inches from the anterior end of the seventh left intercostal space, and of exit rather lower down and further back on the right side. The patient said that he had vomited brown fluid after the injury. There was much abdominal pain, but his general condition was fair. On April 1 there was still much pain, but his general condition was good. CASE IX.--The bullet had entered about 1-1/2 inch in front of the anterior inferior spine on the right side, had gone directly backwards, and had come out in the buttock. The patient, however, suffered very little. On March 31 there was slight tympanites and tenderness in the right iliac fossa. The bowels acted well, and no blood was passed. On April 1 he was very well, and it was considered very doubtful if any viscus was wounded. CASE X.--The point of entrance was in the middle of the right buttock, a little above the level of the trochanter; the exit was through the anterior abdominal wall in the right semilunar line at the level of the umbilicus. The patient was decidedly ill; the abdomen was a good deal distended, and pressure on it caused an escape of gas through the anterior opening. There was a good deal of abdominal tenderness and rigidity. I opened the abdomen outside the right linea semilunaris, and found a perforation in the anterior wall of the _ascending colon_, without any adhesions around, which was easily stitched up. The posterior opening was found about 2 inches lower down, with a piece of omentum firmly adherent to it and completely closing it. As the patient was in a bad state, I thought it better, instead of excising the piece of intestine beyond the holes or tearing off the omentum, to leave the wounds alone, merely cleaning out the peritoneal cavity as well as I could and arranging for free drainage. He rallied from the operation very well, and for twenty-four hours it looked as if he might get better; but he gradually got worse and died on April 2.' The above statistics are particularly valuable, as they give the incidence of abdominal injuries compared with those in general in one definite battle. This amounted to the high number of 15 in 154 or 9.74 per cent. wounded. I am inclined to think that this is a higher proportion than the average of the campaign, and that more of the men must have been exposed in the erect position than was ordinarily the case during the fighting. The statistics also show that 33.33 per cent. of the patients with abdominal injuries died within from twenty-four to twenty-eight hours, and that the percentage of deaths had risen to 73.33 per cent. at the end of the third day. These numbers again seem high, but in this relation it may be noted that, as a small force only was present, and as all the patients were together, Mr. Cheyne had unusually good opportunities for seeing all the cases. One other point is doubtful from the report, and that is what percentage of the wounds were caused by bullets of small calibre. In one case it is definitely stated that the wound was large, and in the second that gas escaped from the wound; both of these may have been instances in which a large bullet, or some expanding form, had been employed, and there is no doubt that the use of such projectiles was more common at this stage of the campaign than it was earlier. _Treatment of injuries to the intestine._--Some general rules for the immediate treatment of all cases may be laid down. First, the patients must be removed with as little disturbance as possible, and absolute starvation must be insisted upon. If the patients be suffering from severe shock, hypodermic injections of strychnine should be administered, or possibly some stimulant by the rectum. After a battle, when these cases may be brought in in considerable number, they should be collected and placed in the same tent. The objection to congregating a number of severely wounded patients together must be disregarded in the face of the manifest advantage of being able to treat all alike in the matter of feeding. After the battles of the Kimberley relief force, Surgeon-General Wilson, at my request, had all the abdominal cases placed in a large marquee, where we were able to carefully watch the whole of the patients from hour to hour, and little chance existed for any indiscretion on the part of the patients in the way of eating or drinking. If possible, the patients should be kept absolutely quiet until they are evidently out of danger. A week's stay at Orange River sufficed for this object in the cases referred to. The avoidance of transport is manifestly of extreme prognostic importance. When feeding is commenced at the end of twenty-four or thirty-six hours, it must be in the form at first of warm water, then milk administered in tea-spoonfuls only. In doubtful cases the use of morphia must be avoided. Operative treatment is required in a certain number of the cases, but in the majority of instances we are met with the extreme difficulty that in a very large proportion of the occasions upon which these wounds are received an exploratory abdominal section is not warranted in consequence of the conditions under which it has to be performed. A word must be added as to these difficulties; they are in part purely of an administrative nature, partly surgical. After a great battle the wounded are numerous, and amongst them a very considerable proportion of the wounds and injuries are of such a nature as to do extremely well if promptly dealt with, and each of these makes small demands on the time of the staff. Abdominal operations, on the other hand, are unsatisfactory from a prognostic point of view, and their performance requires much time and the assistance of a considerable number of the men, who are obliged to neglect the treatment of the more promising cases for those of doubtful issue. This difficulty, although not surgical in its nature, is nevertheless a practical one of great importance and appeals strongly to the Principal Medical Officers in charge of the arrangements. It is only to be avoided by an increase of the staff, which is not likely to be made except on very special occasions. Other difficulties are purely surgical. First, the difficulty of diagnosing with certainty a perforating lesion. In the presence of the fact that many incomplete lesions follow wounds crossing the intestinal area, and that these give rise to modified symptoms, I believe this determination to be impossible without the aid of an exploratory incision. Here we are met with the remaining surgical difficulties--disadvantages such as the absence of sufficient aid to the operating surgeon, difficulties connected with the temperature, wind, and dust, and as to the subsequent treatment of the patient. Again difficulty in obtaining the most important adjunct, suitable water, or indeed any water in a sufficient quantity. It is of course obvious that conditions may exist in which all these troubles may be avoided. Again, the practical difficulty adverted to above does not come in the way when a single man happens to sustain an abdominal wound on the march. Under such circumstances an exploration may be not only justifiable, but obligatory, and the general rules of surgery must be followed rather than such incomplete indications as are suggested below. My own experience led me to the following conclusions: 1. A wound in the intestinal area should be watched with care. In the face of the numerous recoveries in such cases, habitual abdominal exploration is not justified, under the conditions usually prevailing in the field. 2. The very large class of patients excluded by this rule from operation leads us to a smaller and less satisfactory number to be divided into two categories: Patients who die during the first twelve hours. The whole of these are naturally unfit for operation, and their general condition when seen often precludes any thought of it. Patients with very severe injuries, as evidenced by the escape of fæces, or with wounds from flank to flank or taking an antero-posterior course in the small intestinal area. These patients die, and the majority of them will always die whether operated upon or not. The undertaking of operations upon them is unpleasant to the surgeon, as being unlikely to be attended with any great degree of success, whence the impression may gain ground that patients are killed by the operations. None the less, I think these operations ought to be undertaken when the attendant conditions allow, and it is from this class of case that the real successes will be drawn in the future. The history of such injuries, after all, corresponds exactly with what we were long familiar with in traumatic ruptures in civil practice, and now know may be avoided by a sufficiently early interference. The whole question here is one of time, and this will always be the trouble in military work. 3. The expectant attitude which is obligatory under the above rules in doubtful cases, brings us face to face with a large proportion of patients in the early or late stage of peritoneal septicæmia. These cases run on exactly the same lines as those in which the same condition is secondary to spontaneous perforation of the bowel, in which we consider it our duty to operate, and in which a definite percentage of recoveries is obtained. Hence another unpleasant duty is here imposed upon the surgeon. Two such cases on which I operated are recounted above, and although I cannot say they give much encouragement, I should add that in the only one I left untouched, I regretted my want of courage for the five days during which the patient continued to carry on a miserable existence. 4. The treatment of the cases in which an expectant attitude is followed by the advent of localised suppuration presents no difficulty; simple incision alone is needed, and healing follows. As a rule this is a late condition. In one case of injury to the ascending colon recounted above, however, considerable local escape of fæces had occurred, and a successful result was obtained by a local incision on the third day without suture of the bowel. In this case I believe the wound in the bowel to have been of the nature of a long slit, but the surrounding adhesions were so firm as to render any interference with them a great risk, and a successful result was obtained at the cost of a somewhat prolonged recovery. I am convinced that the best course was followed here. (No. 131.) When the suppuration was of a less acute character, it was generally advisable to allow the pus to make its way towards the surface before interference. 5. Cases of injury to the colon in which the posterior aspect is involved should be treated by free opening up of the wound, and either by suture of the bowel or else its fixation to the surface. I operated on one such case, and although the patient eventually died on the eighth day, from septicæmia, he certainly had a chance. Two cases where the opening looked so free that one almost thought the wound could be regarded as a lumbar colotomy did badly; in both infection of the pleura took place, besides extension of suppuration into the retro-peritoneal areolar tissue. In the future I should always feel inclined to enlarge such wounds and bring the bowel to the surface. As regards actual technique the majority of the wounds are particularly well suited to suture; three stitches across the opening and one at either end of the resulting crease sufficed to close the opening effectively. The openings in the small intestine were not as a rule difficult to find, on account of the ecchymosis which surrounded them. From what I have seen stated in the reports given by other surgeons, there seems to have been more difficulty in discovering wounds in the large gut. Under ordinary circumstances the only instruments specially needed are a needle and some silk. At my first two operations, as my instruments had gone astray, the wounds were readily closed by a needle and cotton borrowed from the wife of a railway porter. If aseptic sponges or pads are not available, boiled squares of ordinary lint may be employed for the belly, and towels wrung out of 1 to 20 carbolic acid solution used to surround the field of operation. Whenever there is any likelihood of the necessity for operations, water boiled and filtered should be kept ready in special bottles. When septic peritonitis was already present, the ordinary procedure of dry mopping, followed by irrigation, was necessary, before closing the belly. The after-treatment should be on the usual lines as to feeding, &c. I am unaware to what degree success followed intestinal operations generally during the campaign. I saw only one case in which the small intestine had been treated by excision and the insertion of a Murphy's button in which a cure followed: this case was in the Scottish Royal Red Cross hospital under the care of Mr. Luke. I heard of two cases in which the large intestine was successfully sutured, and of one other in which recovery followed the removal of a considerable length of the small bowel for multiple wounds. In concluding these most unsatisfactory remarks, I should add that the impressions are those that were gained as the result of the conditions by which we were bound in South Africa, and which might recur even in a more civilised region. Under really satisfactory conditions nothing I saw in my South African experience would lead me to recommend any deviation from the ordinary rules of modern surgery, except in so far as I should be more readily inclined to believe that wounds in certain positions already indicated might occur without perforation of the bowel when produced by bullets of small calibre; and further in cases where I believed the fixed portion of the large bowel was the segment of the alimentary canal that had been exposed to risk, I should not be inclined to operate hastily. A careful consideration of the whole of the cases that I saw leaves me with the firm impression that perforating wounds of the small intestine differ in no way in their results and consequences when produced by small-calibre bullets, from those of every-day experience, although when there is reason merely to suspect their presence an exploration is not indicated under circumstances that may add a fresh danger to the patient. _Wounds of the urinary bladder._--Perforating wounds of the bladder are the injuries nearest akin to those we have just considered, but a great gulf separates them, in so far as the escape of a few drops or even a considerable quantity of normal urine does not necessarily mean peritoneal infection. The difference in this particular was very forcibly demonstrated in my experience, since an uncomplicated perforation of the bladder in the intra-peritoneal portion of the viscus proved to be an injury that not infrequently recovered spontaneously, I believe in a considerable proportion of the cases. I include only one such case in my list because it was the only example which happened to be under my personal observation during its whole course, but from time to time I was shown several others in which the position of the external apertures and the transient presence of hæmaturia left little doubt as to the nature of the injury. The case recounted above, No. 190, is of especial interest, since the patient recovered from an injury which involved both the bladder and a fixed portion of the large intestine in contact with its posterior surface. In another, No. 194, a transient inflammatory thickening pointed to a local inflammation of a non-infective character, since no suppuration ensued, and this may have been a case of extra-peritoneal wound; on the other hand, the bladder may have entirely escaped injury. In wounds of the portions of the viscus not clad in peritoneum, as a rule, a very different prognosis obtains. Two typical cases are related, which I believe fairly represent the general results which follow when the bladder is either wounded behind the symphysis or at the base. The first case, No. 195, exemplifies a very characteristic form of wound when small-calibred bullets are concerned. The bullet, taking a course more or less parallel to that of the wall of the viscus, cut a long slit in its anterior wall. This bullet in its onward passage comminuted the horizontal ramus of the pubes, and lodged in the thigh. Into the latter region the greater part of the extravasated urine escaped. I think the history of this case fully shows that I made a blunder in not performing a proper exploration, instead of contenting myself with an incision in the thigh. My only excuse was that the patient at the time I saw him was in a very collapsed state, and a severe grade of abdominal distension suggested that septic peritonitis was already in an advanced stage. In point of fact, the patient at once improved, sufficiently so to be able to undergo a second exploration at a later date by Mr. Hanwell at the Base, only dying of septicæmia at the end of twenty-one days. Even a free supra-pubic vent might, I believe, have given him a chance of life. When the perforation was at the base of the bladder, however, the prognosis was very bad, and, as far as I know, not a single patient escaped death. The increase of risk in an extra-peritoneal wound of this viscus is indeed very great, while an intra-peritoneal perforation may be considered an injury of lesser severity, provided the urine be of normal character. (194_a_) _Possible wound of the bladder._--Wounded at Magersfontein. _Entry_ (Mauser), immediately above the symphysis pubis; _exit_, in the buttock, behind the tip of the left great trochanter. The man was struck while advancing, and fell, thinking at the time 'that he was struck in the foot.' He lay twelve hours on the field, and passed water for the first time when the bearer removed him. During the next two days he passed urine only twice, and no blood was noticed. The bowels acted on the evening of the third day. When seen on the fourth day he complained of aching pain in the lower part of the belly, and a concentric patch of tender induration extended for about 1-1/2 inch around the wound. The abdominal wall was moving well. The tongue was clean and moist. There was no blood in the urine, and micturition was not frequent. Temperature 99.4°. Pulse 80, good strength. The patient was then sent to the Base. At the end of seventeen days there was still a little tenderness in the left iliac fossa; but the man was otherwise well, and at the end of a month he was sent home. (195) _Extra-peritoneal wound of the bladder._--Wounded at Magersfontein. _Entry_ (Mauser), at the fore part of the right buttock. No exit. The patient was seen on the third day. He had an expression of extreme anxiety, and complained of very great pain in the abdomen and thigh. The abdomen was greatly distended and tympanitic, and the left thigh and groin were very much swollen and oedematous, with some redness of surface. Temperature 100°, pulse 120. No sickness, tongue moist, bowels confined. Retention of urine. The condition of the patient was very grave; but he was anæsthetised, clear urine was withdrawn from the bladder by catheter, and an incision was made into the thigh just below the inner third of Poupart's ligament, where fluctuation was evident. Two pints of bloody urine were evacuated, and when a finger was introduced it passed over a fracture of the pubes into the pelvis, but not into the peritoneal cavity. In view of the patient's condition it was not thought wise to proceed further, and he somewhat improved later, and was sent to the Base. Loss of power in the right lower extremity pointed to injury to the anterior crural nerve. On the patient's arrival at Wynberg there were signs of local peritonitis in the lower half of the abdomen, and all his urine was passed from the wound in the left thigh. Some days later this wound was enlarged to allow of the freer exit of pus, and a fragment of bone was removed. The wound granulated healthily, but the man steadily emaciated and lost ground, with signs of chronic septicæmia, and he died on the twenty-first day. At the _post-mortem_ examination a transverse wound of the anterior wall of the bladder behind the pubes, below the peritoneal reflexion, was found gaping somewhat widely, and 2 inches in length. There was little sign of previous peritonitis. The retained bullet was discovered beneath the femoral vessels in the left thigh. (196) _Extra-peritoneal perforation of the bladder._--Wounded at Paardeberg. _Entry_ (Mauser), 3 inches above the left tuber ischii; _exit_, above the symphysis, immediately over the right margin of the penis. The patient was retiring to fetch ammunition when shot. Urine was noted to escape from both apertures the day after, and this continued until he was sent down to the Base on the fourteenth day. The patient was then considerably emaciated, complained of great pain, especially down the left thigh (sciatic nerve), the temperature averaged 100°, the pulse 80, tongue clean and moist, bowels acted regularly, no sign of injury to the rectum. He was taking food fairly, but was very sleepless. Urine was passed per urethram, and also escaped by both wounds. The abdomen was flaccid and sunken, respiratory movements being confined to the upper half. As there was evidence of considerable infiltration in the buttock, the original entry wound was enlarged, and a catheter was tied into the bladder. Little change occurred in the symptoms and the local condition, urine and pus continued to escape freely from the posterior wound, and the patient gradually sank, dying on the thirty-eighth day. At the _post-mortem_ examination the peritoneum was found intact and unaltered, but there was extensive pelvic cellulitis around the bladder, a large slough and some pus lying in the cavum Retzii. An aperture of entry still open existed in the centre of the anterior wall of the bladder, and a patent exit opening at the base of the trigone. The bullet had passed out of the pelvis by the great sciatic notch. The above remarks and cases sufficiently set forth the prognosis in these injuries. For the intra-peritoneal lesions an expectant plan of treatment may be followed by uncomplicated recovery. Mention has already been made of a case in which a Mauser bullet was retained in the bladder and was subsequently passed per urethram. In such a case a cystotomy would be indicated were the bullet discovered in the viscus. As to extra-peritoneal injuries it is difficult to lay down guiding lines. I believe the ideal treatment would be a supra-pubic cystotomy and drainage of the bladder by a Sprengel's pump apparatus, such as we employ at home. Under these circumstances, with the possibility of keeping the bladder actually empty, I believe good results might be obtained. Certainly drainage of the bladder by a catheter tied in proved worse than useless, and I very much doubt whether a simple supra-pubic opening would give any better results under the circumstances under which a patient has to be treated in a Field hospital. Cases might, however, occur in which oblique passage of the bullet cuts a groove and makes a large opening in the peritoneum-clad portion of the viscus. Under satisfactory conditions a laparotomy would be here indicated. I take it that this condition would most probably be accompanied by retention of bloody urine, which fact would arouse suspicion. INJURIES TO THE SOLID ABDOMINAL VISCERA _Wounds of the kidney._--Tracks implicating the kidneys were of comparatively common occurrence. As uncomplicated injuries they healed rapidly, and without producing any serious symptoms beyond transient hæmaturia. The nature of the lesion appeared to vary with the direction of the wound. In many cases a simple puncture no doubt alone existed, an injury no more to be feared than the exploratory punctures often made for surgical purposes. In other cases the wounds may have been of the nature of notches and grooves. Two of the cases recounted below were of a more severe variety; in one (No. 201) both kidneys were implicated by symmetrical wounds of the loin, and in the case of the right organ a transverse rupture was produced, which was followed by the development of a hydro-nephrosis, and later by suppuration. This injury was probably the result of a wound from a short range, as the patient was one of those wounded in the early part of the day at the battle of Magersfontein. It was complicated by a wound of the spleen and an injury to the spinal cord producing incomplete paraplegia accompanied by retention of urine. The last complication was responsible for the death of the patient, since ascending infection from the bladder led to the development of pyo-nephrosis and death from secondary peritonitis. Case 202 is an instance of a transverse wound of the upper part of the abdominal cavity; it is impossible to say what further complications were present. The early development of a tympanitic abscess suggested an injury to the colon, but this was not by any means certain. The condition of the kidney was very likely similar to that in the last case, but the ultimate recovery of the patient left this a matter of doubt. The case was also one dependent on a short-range wound, since the patient, one of the Scandinavian contingent, was wounded at Magersfontein during close fighting. The common history of the symptoms after a wound of the kidney was moderate hæmorrhage from the organ, persisting for two to four days. In one of the cases recounted below the hæmaturia was accompanied by the passage of ureteral clots, but this was not a common occurrence. For the sake of comparison I have included one case of wound of the kidney from a large bullet, in which death was due to internal hæmorrhage. In this instance the injury was a complex one, the lung certainly, and the back of the liver probably, being concurrently injured. None the less if the same track had been produced by a bullet of small calibre I believe the injury would not have proved a fatal one. I never saw such free renal hæmorrhage in any of the Mauser or Lee-Metford wounds. (197) _Wound of right kidney._--Wounded at Modder River while lying in the prone position; retired 100 yards at the double with his company, and walked a further 1-1/2 mile. There was very slight bleeding. _Entry_ (Mauser), in the tenth right intercostal space in the mid-axillary line; _exit_, in eleventh interspace, 2 inches from the spinous processes. Cylindrical blood-clots, 3 inches in length, were passed on the first two occasions of micturition after the accident, and the urine contained blood. For four days he could only lie on the wounded side. When seen on the third day the urine was normal, and there were no signs of injury to either thoracic or abdominal viscera. He returned to England well at the end of a month. (198) _Wound of right kidney._--Wounded at Modder River while kneeling to dress another man's wound. _Entry_ (Mauser), in the seventh right intercostal space in the nipple line; _exit_, 1 inch to the right of the twelfth dorsal spine. The man was carried off the field, and during the first day vomited frequently. For two days there was blood in his urine, and he passed water four to five times daily. He returned to duty at the end of three weeks. (199) _Wound of the left kidney._--Wounded at Magersfontein. _Entry_ (Mauser), 2 inches to the left and 1 inch below the left nipple. No exit. Lying in prone position when struck. Bloody urine was passed at normal intervals for four days, when the hæmaturia ceased. No thoracic signs, and no other sign of abdominal injury. There was tenderness in the left loin below the twelfth rib for some days, possibly over the position of the bullet, but the latter was neither localised nor removed. (200) _Wound of the right kidney._--Wounded at Magersfontein while retiring on his feet. _Entry_ (Mauser), immediately to the right of the second lumbar spinous process; bullet retained and lay beneath margin of ninth right costal cartilage. The man passed urine containing blood twelve times during the first day, and hæmaturia continued until the evening of the third day. On the third day the belly was tumid and did not move well; there was no dulness in the right flank. Pulse 120, fair strength. Temperature 99°. Respirations 20. Tongue moist, bowels confined for four days. The fifth day the pulse fell to 76, and the bowels were moved by an enema. Great tenderness over bullet. The tenderness persisted over the bullet and also in the right flank until the tenth day, when the bullet was removed. At the end of a month the patient returned to England well but during the third week there was occasionally blood in the urine. (201) _Wound of both kidneys (rupture of right) and spleen._--Wounded at Magersfontein. _Entry_ (Mauser), (_a_) 1 inch to right of second lumbar spinous process; (_b_) above angle of left ninth rib: _exits_, (_a_) 1 inch internal to right anterior superior iliac spine; (_b_) in seventh intercostal space in mid-axillary line. The wound on the right side gave rise to a lesion of the lumbar bulb (see p. 315), and the patient suffered throughout with retention. There was complete paralysis of the right lower extremity, both motor and sensory. For ten days there was hæmaturia, and very severe cystitis developed, while the patient suffered with severe abdominal pain. The cystitis persisted, also retention, which gradually gave way to dribbling, while irregular rise of temperature and tenderness in the loins pointed to ascending inflammation in the ureters. The patient gradually lost ground, and a month later suddenly developed signs of peritonitis, severe vomiting, distension, and dulness in the right flank; and in two days he died. At the _post-mortem_ examination the following condition was found:--On the right side general pleural adhesions, recent lymph over ascending colon and cæcum, [Symbol: ounce]vj of bloody fluid in a localised cavity between colon, kidney, stomach, and liver. Lower quarter of right kidney in half its width separated from main part of organ, yellow in colour, and enveloped in disintegrating clot. Blood-staining of psoas sheath; no injury to vertebral column or to bowel detected. On the left side recent pleural adhesions and consolidation of base of lung, rent of diaphragm; spleen soft and disorganised and presenting a yellow cicatrix at its upper end, and at antero-external aspect of left kidney was a soft yellow puckered spot about the size of a florin, dipping 3/4 of an inch into the organ, which was otherwise healthy, beyond congestion. The capsules of both kidneys were adherent, but there was no sign of suppuration. (202) _Wound of right kidney. Traumatic hydronephrosis._--Wounded at Magersfontein. _Entry_ (Lee-Metford), in the eleventh intercostal space in the posterior axillary line; _exit_, in the tenth right interspace, in mid axillary line. The patient was in the prone position when struck, and lay on the field from 5 A.M. until 6 P.M. There was no sickness, and the bowels did not act. When seen on the fourth day he was cheerful, but in some pain. The abdominal wall moved well, but was rigid; there was some general distension, and very marked local distension of the gastric area extending across to the right, so that a depressed band extended between the upper and lower parts of the belly. There was marked local dulness in the right flank, which did not shift on movement; the abdomen was elsewhere tympanitic. Tongue furred, bowels confined; there has been no sickness, and no hæmatemesis. Urine normal, and in good quantity. Temperature 100°. Pulse 84, good strength. There was impairment of sensation in the area of distribution of the external cutaneous and crural branch of the genito-crural nerves. On the sixth day the bowels acted, after the administration of [Symbol: ounce]j of sulphate of magnesia, and the distension was much lessened, although the belly retained its unusual appearance. The dulness in the flank was unaltered. Temperature 100.8°, pulse 92. A week later the man was much improved, suffering no pain. Temperature ranged from 99 to 100°, and the pulse about 80. The abdomen was normal in appearance, except for general prominence of the right thorax in the hepatic area. During the third week a large tympanitic abscess developed at the aperture of exit, and this was opened (Mr. S. W. F. Richardson) through the chest, and a large collection of foul-smelling pus, but no fæcal matter, evacuated. The patient again improved, but a fortnight later a swelling and apparent signs of local peritonitis developed in the right inguinal and lower umbilical and lumbar regions. An incision made over this, however, disclosed a normal peritoneal cavity and was closed. At the end of ten weeks the patient was sent to the Base hospital; a large firm swelling was then evident, extending from the liver to the inguinal region, and nearly to the median line. This gradually increased until it filled half the belly; it was at first thought to be a retro-peritoneal hæmatoma (similar to that described in case 194), but it became quite soft and fluctuating, and was then tapped, and [Symbol: ounce]50 of blood-stained fluid, which proved to be urine, were removed. The urine rapidly reaccumulated, and the cavity was then laid freely open. Urine continued to discharge in large quantity for two months, the man meanwhile remaining well, and passing a somewhat variable daily quantity of urine ([Symbol: ounce]xxiv-[Symbol: ounce]lx). At the end of six months the wound had healed, and the man was serving as an orderly in the hospital. (203) _Wound of right kidney and lung._--Wounded near Paardekraal, while crawling on hands and knees. _Entry_ (Martini-Henry, or small bullet making lateral impact), just above the right nipple, opening ragged and large, bullet retained. There was very severe shock, accompanied by vomiting, but no hæmatemesis. Later there was some hæmoptysis. Pulse 120, respirations 48. Twenty-four hours later the vomiting had ceased; the patient had passed a restless night, in spite of an injection of morphia. He lay on his right side, pale and collapsed, but answered questions and was quite collected. Pulse imperceptible, respirations 56; the abdomen moved freely. The urine had been passed twice, and was chiefly blood. The patient died shortly afterwards, apparently mainly from internal hæmorrhage, although restlessness was not a prominent feature. As the Column was on the march no autopsy was possible. The treatment of uncomplicated wounds of the kidney consisted in the ensurance of rest, either alone, or with the administration of opium if the hæmaturia was severe. The after-treatment in the event of the development of hydronephrosis is on ordinary lines. Tapping, or incision followed by extirpation of the injured viscus, if the less severe procedures failed. I never saw a case where renal hæmorrhage suggested the removal of the kidney as a primary step, and much doubt whether such a case is likely to be met with, as the result of a wound from a bullet of small calibre. _Wounds of the liver._--Wounds of the liver were, I believe, responsible for more cases of death from primary hæmorrhage than those of the kidney. I heard of a few cases in which this occurred, although I never saw one. Case 204 is of considerable interest as illustrating the result of an injury to one of the large bile ducts. Putting the deaths from primary hæmorrhage on one side, the prognosis in hepatic wounds was as good as in those of the kidneys. A few fairly uncomplicated cases are quoted below, but wounds of the liver occurred in connection with a large number of other injuries both of the chest and abdomen, and except in the case of wound of the stomach, recorded on page 425, No. 164, and in case 188, I never saw any troublesome consequences ensue. _Nature of the lesions._--I never saw any case of so-called explosive lesion of the liver, such as have been described from experimental results; this may have been due to the fact that such patients rapidly expired, but such were never admitted into the hospitals. The most favourable cases were those in which a simple perforation was effected; such were usually attended by a practical absence of symptoms, unless a large bile duct had been implicated, when a temporary biliary fistula resulted. Biliary fistulæ were, however, much more common when the bullet scored the surface of the organ. One such case is recounted under the heading of injuries to the stomach, No. 164. Here a deep gaping cleft with coarsely granular margins extended the whole antero-posterior length of the under surface of the left lobe, and the escape of bile was free. This was the nearest approach to one of the so-called explosive injuries I met with. Case 207 is an example of a superficial injury from a bullet possibly of small calibre in which a superficial groove was followed by temporary escape of bile, and it is of interest to note a very similar condition in a shell injury (No. 210) recorded on p. 477. Although both these cases recovered, I think notching and superficial grooving must be considered much more serious injuries than pure perforation. (See case 188, p. 442.) The symptoms observed in these injuries have been already indicated in the above description of the nature of the lesions. They consisted in the pure perforations of practically nothing, in the grooves or the perforations implicating a large duct in the escape of bile. In two of the cases in which a biliary fistula was present transient jaundice was noticed. In many cases the accompanying wound of the diaphragm gave rise to much discomfort; again, in the transverse wounds the action of the heart was often affected by the local cardiac shock accompanying the injury. In one case in which the colon was at the same time wounded (No. 188), an abscess formed at the site of the hepatic wound, as might have been expected. As uncomplicated injuries, these wounds were little to be feared. Except as a source of hæmorrhage in rapidly dying patients, I never heard of a fatality. As a complication of other injuries, however, the wound of the liver, as has been shown, was sometimes of importance. It was remarkable in case 204 how little trouble the biliary fistula gave rise to, although the bile was discharged across the pleural cavity. The treatment consisted in rest, and morphia in the cases of suspected progressive hæmorrhage, or in the presence of great pain. In cases where bile was escaping, it was important to ensure a free vent for the secretion. (204) _Wound of liver. Biliary fistula._--Wounded at Magersfontein. _Entry_ (Lee-Metford), below the seventh rib, in the left nipple line; _exit_, through the eighth rib, in the mid axillary line on the right side. The patient lay for seventeen hours on the field, during which time the bowels acted once, but there was no sickness. The bowels then remained confined. When seen on the third day the abdomen was normal and the chest resonant throughout on both sides; bile to the amount of some ounces escaped from the wound on the right side. Suffering no pain; temperature 99°, pulse 100. The bowels acted freely the following day. During the next fortnight there was little change; [Symbol: ounce]ii-iij of bile escaped daily, and there was occasional diarrhoea. At the end of that time, however, the temperature rose; there was local redness and evidence of retention of pus. The wound was therefore enlarged, some fragments of rib removed, and a drainage tube inserted. After this the temperature fell, and for the next two months the patient suffered little except from the discharge from the sinus; this persisted for three months, becoming less in amount and less bile-stained, the fistula eventually closing in the fourteenth week, when the patient was sent home on parole. (205) _Wound of liver_.--_Entry_ (Mauser), 1 inch below and to the left of the ensiform cartilage; _exit_, in the sixth right intercostal space, just behind the posterior axillary line. The trooper was sitting bolt upright on his horse at the time; both were shot and fell together. 'Stitch' on coughing or laughing was the only sign noted after the accident; this rapidly subsided. (206) _Wound of the liver._--Wounded at Magersfontein. _Entry_ (Mauser), through the seventh left costal cartilage, 1 inch from the base of the ensiform cartilage; _exit_, below the twelfth rib 2 inches to the right of the lumbar spines. The patient lay on the field some hours and was brought in at night very cold, and suffering with much shock. No signs of abdominal injury developed, but the pulse remained as slow as 66 for some days, and there was some pain and stiffness about back and sides, or on taking a deep breath. These signs persisted some days, but no others developed, and in six weeks the patient returned to duty. Some three months later this patient suffered from a short severe attack suggesting local peritonitis, but he again returned to duty. (207) _Wound of the liver._--Wounded at Tweefontein. _Entry_, in eighth intercostal space in right mid axillary line; _exit_, 1-1/2 inch below the point of the ensiform cartilage, 1/2 an inch to the right of the mid line. The wounds were large, and although the impact had been oblique, they were possibly produced by a Martini-Henry or Guedes bullet. On the second day bile began to escape from the exit aperture, and this together with a little pus continued to be discharged for a week, when the wound rapidly healed up. The only symptom which occasioned any trouble was a stitch on inspiration, probably attributable to the wound of the diaphragm. There was no fracture of the rib. (208) _Wound of the liver._--Wounded outside Heilbron at a range of fifty yards. _Entry_ (Mauser), in the tenth right interspace 2 inches to the right of the dorsal spines; _exit_, through the gladiolus, immediately to the right of the median line, and just above the junction with the ensiform cartilage. There was considerable shock on reception of the injury, and a great feeling of dizziness. Continuous vomiting set in and persisted for the first two days, then became occasional, and ceased only at the end of a week. There was also occasional hiccough, and stitch on drawing a long breath. The respiration was shallow and rapid. The bowels acted twice shortly after the injury. The pulse was rapid and small, and a week after the injury was still above 100. The abdomen was then normal and moving symmetrically, and the respiration fairly easy. There were no signs of chest trouble, but some mucous expectoration. A slight icteric tinge existed. The patient made a good recovery. _Wounds of the spleen._--Uncomplicated wounds of the spleen were necessarily rare, and beyond this the strict localisation of a track to the spleen is not a matter of great ease. None the less the spleen must have been implicated in a considerable number of the wounds crossing the chest and abdomen. I know of only one case in which a wound which crossed the splenic area caused death from hæmorrhage, and of this I can give no details, as I never saw the patient. In this instance, however, a wound of the spleen was diagnosed after death from the position of the wounds. The patient continued to perform his duty as an officer in the fighting line for at least an hour after being struck, and then died rapidly apparently from an internal hæmorrhage. In case No. 201, included amongst the renal injuries, a wound of the spleen existed, but had given rise to no symptoms, and at the time of death, some three weeks later, was cicatrised. The only other assertion of importance that I can make is, that, as far as I could judge, wounds of the spleen from bullets of small calibre were not, as a rule, accompanied by hæmorrhage, since I never saw a case in which dulness in the left flank suggested the presence of extravasated blood, and in no case that I saw was there any history of general symptoms pointing to the loss of blood. This is only to be explained by our similar experience with regard to wounds of the liver unaccompanied by puncture of main vessels, and perhaps hæmorrhage is still less to be expected in the case of the spleen, in consequence of the contractile muscular tunic with which the organ is provided. I can quote no case of certain injury to the spleen, except that already referred to discovered at a _post-mortem_ examination, but many wounds were observed in positions of which the following may be taken as a type. _Entry_, through the seventh left costal cartilage, 3/4 of an inch from the sternal margin; _exit_, 2-1/2 inches from the left lumbar spines at the level of the last rib. As an instance of the doctrine of chances I might quote the position of the wound in the patient who lay in the next bed. Both patients were wounded while fighting at Almonds Nek. _Entry_, through right seventh costal cartilage, 3/4 of an inch from the sternal margin; _exit_, 1-1/2 inch from the lumbar spines, at the level of the last right rib. In neither of these cases did anything except the position of the external apertures point to the infliction of visceral injury. _General remarks as to the prognosis in abdominal injuries._ The prognosis in each form of individual visceral injury has been already considered, but a few points affecting these injuries as a class should perhaps be further considered. First, as to the influence of range on the severity of the injuries inflicted; I am not able to confirm the greater danger of short range, except in so far as there is no doubt that more shock attends such injuries, and possibly some of the most severely wounded were killed outright as a direct consequence of the greater striking force of the bullet. Among the cases in which but slight effects were noted, however, many were said to have been hit within a range of 200 yards, as for instance the two injuries quoted under the heading of wounds of the spleen. I personally saw no cases in which explosive injuries of the solid viscera were to be ascribed to this cause. Secondly, as to the immediate prognosis in all abdominal injuries, the ensurance of rest and limitation as far as possible of transport were of the highest importance, either in the case of wound of the alimentary canal, or in wounds of the solid viscera in which hæmorrhage was a possible result. Thirdly, as to the later prognosis in these injuries; very few men are fit to resume active service without a prolonged period of rest. In spite of the insignificance of the primary symptoms, or of the favourable course taken by the injuries, active exertion was almost always followed for some months by the appearance of vague pains and occasionally by indications of recurrent peritoneal symptoms, pointing to the disturbance of quiescent hæmorrhages, or of adhesions. Wounds of the kidney are apparently those least liable to be followed by trouble. Lastly, the prognosis was influenced in the case of many of the viscera by coexisting injury to other organs or parts. For instance, at least thirty per cent. of the abdominal wounds were complicated by wound of the thorax; and in the lower segment of the abdomen injury to the extra-peritoneal portions of the pelvic organs was common. Both the immediate and ultimate prognosis were influenced greatly by this fact. As to the individual injuries: 1. Wounds in the intestinal area, except in certain directions, often traverse the abdomen without inflicting a perforating injury on the bowel. 2. If the alimentary canal is perforated, injuries in certain segments, even if perforating, may be followed by spontaneous recovery. I should say the prognosis from this point of view is best in the ascending colon, then in the rectum; after these most favourable segments, I should place the others in the following order: stomach, sigmoid flexure, descending colon. As to perforating wounds of the transverse colon and small intestine, I believe spontaneous recovery to be very rare. 3. Wounds of the solid viscera generally, usually heal spontaneously, and give no trouble unless one of the great vessels has been injured. I include in this category all organs except the pancreas, of wounds of which I had no experience. 4. Wounds of the bladder, if of the nature of pure perforations in the intra-peritoneal segment, often heal spontaneously. 5. As a rule, injuries to the organs in their intra-peritoneal course have a far better prognosis than those which implicate the organs in their uncovered portions. 6. The small calibre of the bullet is alone responsible for the favourable results observed. 7. The danger or otherwise of an intestinal injury depends mainly on mechanical conditions; for instance, the fixity of the ascending colon, and its comparative freedom from a covering of small intestine capable by movement of diffusing any infective material, account chiefly for such favourable results as are seen when that segment of the bowel is implicated. WOUNDS OF THE EXTERNAL GENITAL ORGANS Wounds of the _scrotum_ were not uncommon, especially in connection with perforations of the upper part of the thigh. They offered no special feature, beyond the common tendency of every-day experience to the development of extensive ecchymosis. Wounds of the _testicles_ I saw on several occasions. I remember only one out of some half-dozen in which castration became necessary. I was told of one case, for the accuracy of which I cannot vouch, in which destruction of one testicle was followed by an attack of melancholia, culminating in the suicide of the patient. Wounds of the _penis_ also occurred, but as a rule were unimportant. I append a case, however; in which the penile urethra was wounded, which is of some interest. (209) Wounded at Heilbron. Range 1,500 yards. _Entry_, 2-1/2 inches below the right anterior superior iliac spine; the bullet traversed the groin superficially in the line of Poupart's ligament, emerged, and crossed both penis and scrotum. The trooper was in the saddle when struck, and the penis probably somewhat coiled up. Three wounds were found, one at the junction of the penis and scrotum which opened the urethra, a second one about 3/4 of an inch along the under surface of the penis, and a third on the left side of the base of the prepuce. A considerable amount of oedema and ecchymosis of the scrotum developed, but no extravasation of urine. A catheter was kept in the urethra for some days, and the opening eventually closed by granulation. I only once saw a patient with an injury to the deep urethra; in this case concurrent injury to other pelvic organs led to death on the third day. As a good many of the patients with pelvic wounds died rapidly, the accident may have been more common than my experience would suggest. FOOTNOTES: [19] _British Med. Journal_, May 12, 1900, i. 1195. [20] 'On Traumatic Rupture of the Colon.' _Annals of Surgery_, vol. xxx. 1899, p. 137. [21] Two of these died. [22] The cases of injury to the solid viscera are those only which happen to be quoted in the text, and give no idea of relative mortality. [23] _British Medical Journal_, May 12, 1900, vol. i. p. 1194. CHAPTER XII ON SHELL WOUNDS The title of this work hardly allows of its conclusion without a brief mention of the shell wounds observed during the campaign. As already pointed out, these formed but a very small proportion of the injuries treated in the hospitals, and beyond this they possessed comparatively small surgical interest, since, as a rule, the features presented were those of mere lacerated wounds, while the more severe of the cases which survived only offered scope for operations of the mutilating class so uncongenial to modern surgical instincts. The fatal wounds consisted in extensive lacerations resulting in the destruction of the head or limbs, the laying open of the abdominal or thoracic cavities, or the production of visceral injuries beyond the possibility of repair. Of such injuries no further mention will be made. A very great variety of shells was employed during the campaign, especially on the part of the Boers, and the frontispiece gives some idea of these. The photograph was taken by Mr. Kisch after the relief of Ladysmith. For the want of more extended knowledge I shall confine myself to the description of a few injuries caused by two classes of large shell, those of the Vickers-Maxim or 'Pom-pom,' and two varieties of shrapnel. The large shells employed may be divided into classes according to the metal used in their construction, and the nature of the explosive with which they were filled. These details are of some surgical import, because they affect the nature of the fragments into which the shells are broken up. Fragments of shells constructed with cast iron and burst with powder, and also of forged steel exploded with lyddite, are depicted in fig. 90. [Illustration: FIG. 90.--A, B, D. Fragments of 200 lb. forged Steel Howitzer Shell exploded by lyddite. C. Fragment of Cast-iron Shell exploded by powder. B exhibits transverse markings which might be mistaken for the lines seen in the Boer segment shells, but which really correspond to the area of fixation of the copper driving band] Examination of fragment C of a cast-iron shell exploded by powder shows the characteristic granular fracture, and edges, although sharp, yet of a comparatively rounded nature. The fragment is also heavier for its surface measurement, as the metal is thicker than that seen in the remaining fragments, although the cast-iron shell was of a much smaller calibre than the steel one. The lesser degree of penetrative power, and increased capacity to contuse, possessed by such fragments are obvious. A B and D are fragments of a large forged steel howitzer shell exploded by lyddite, such as were cast by our guns. The photograph well shows the more tenacious structure of the metal in the incomplete longitudinal fissuring exhibited, while the margins are of a sharp knifelike character, well calculated to penetrate or, in the case of superficial injuries, to produce wounds of a more sharply incised character than the cast-iron shell. Fragments A and B also show an appearance suggestive of partial fusion, characteristic of high explosive action, in the turning of the prominent margins. The larger fragments of such shells were responsible for the most serious mutilating injuries, while small fragments sometimes caused comparatively simple perforating wounds. I remember a fragment of the fused character not larger than a small nut which had perforated the front of the thigh of a Boer, and lodged near the inner surface of the femur. Removal of the fragment was followed by a free gush of hæmorrhage. When the wound was opened up an opening was found in the external circumflex artery, hæmorrhage from which had been controlled by the impaction of the piece of shell. As an example of the cutting power of sharp fragments of shell I might instance the case of another Boer in whom light passing contact had been made by the missile. A gaping incised wound extended from above the angle of the scapula down to the outer surface of the buttock. The wound involved the latissimus dorsi, and the external and internal oblique muscles of the abdomen. The separate muscular layers were sharply defined in the lateral parts of the floor of the wound, and remained so for some time during the gradual contraction of the large granulating surface produced. The degree of contusion was in fact slight, while the incised character was strongly marked. In some cases the fragments merely struck the soldiers on the flat without producing any wound. In one such case a blow upon the epigastrium was, according to the patient, followed by the vomiting of a considerable amount of blood. A fluid diet was ordered, and no further ill effects were noted. The following case illustrates an oblique blow of a perforating character, which was nevertheless recovered from. [Illustration: FIG. 91.--Various portions of Brass Percussion and Time Fuses] (210) _Shell-wound of abdomen. Injury to liver._--Wounded at Paardeberg by a fragment of shell. Aperture of entry, a ragged opening in the median line. The fragment of shell was retained over the ninth costal cartilage in the nipple line. The wound bled freely, but the man was taken into camp, and then four miles on to the hospital, where he was anæsthetised and the fragment extracted. The wound of entry was at the same time enlarged, cleansed, and partly sutured. The patient vomited once after the anæsthetic, and the bowels remained confined for three or four days after the injury. The extraction wound healed readily, but a considerable amount of slimy, bile-stained discharge was still escaping from the ragged entrance wound on the man's arrival at the Base on the fourteenth day. The abdomen was then normal in appearance, and as to physical signs, except for a tympanitic note over the hepatic area to the right of the wound. The temperature was normal, the pulse 90, the tongue clean, and the bowels were acting. At the end of four weeks pleurisy, with effusion, developed on the right side; the chest was aspirated and [Symbol: ounce]xx of clear serum drawn off. The man then rapidly improved; the bile-stained discharge ceased at the end of five weeks, and a small granulating wound eventually closed at the end of two months, when the man returned to England. Fig. 91 is inserted to illustrate the multifarious nature of the fragments into which the component parts of shells may break up. The pieces are for the most part of brass, and formed parts of either time or percussion fuses. Fig. 92 represents the one-pound Vickers-Maxim shell in its actual size. The wounds produced by this shell are of some interest, since the Vickers-Maxim may be said to have been on trial during this campaign. The general opinion seems to have been to the effect that the moral influence produced by the continuous rapid firing of the gun and the attendant unpleasant noise were its chief virtues. A considerable number of wounds must, however, have been produced by it, which, if not of great magnitude and severity, were, at any rate, calculated to put the recipients out of action, and these wounds, moreover, were slower in healing than many of the rifle-bullet injuries. The shell is so small that it was said to occasionally strike the body as a whole, and perforate. I was shown a case in which a wounded officer was confident that an entire shell had perforated his arm. The entry wound was at the outer part of the front of the forearm, the exit at the inner aspect of the arm, just above the elbow. Two ragged contused wounds existed, which healed slowly, but no serious nervous or vascular injury had been produced. Although it is probable that only a fragment perforated in this case, it is of interest in connection with the following. In a case shown to me by Sir William Thomson in the Irish Hospital at Bloemfontein, an entire shell had passed between the left arm and body of a trooper, perforating the haversack, as also a non-commissioned officer's notebook contained within it, without exploding. The only injury sustained by the trooper was a contusion on the inner aspect of the elbow-joint, with slight signs of contusion of the ulnar nerve. The case is of some importance, as showing that a comparatively resistent body can be perforated without necessary explosion on the part of the shell; hence the possibility of a similar perforation of the soft parts of the body. [Illustration: FIG. 92.--Unexploded 1-lb. Vickers-Maxim Shell. (Actual size)] Fig. 93 is of a number of fragments of Vickers-Maxim shells, and it was by such that the great majority of the wounds were produced. Wounds from fragments of these shells were, indeed, not at all rare. They were met with on any position; but, as far as my experience went, they were more common on the lower extremities than in other parts of the body, if the sufferers were in the erect position when wounded. I saw a good many wounds in the neighbourhood of the knee, some of which implicated the joint. When the injuries were received by patients in the lying or crouching positions, any part of the body was equally likely to be affected, or, again, the presence of large stones or rocks in the vicinity might determine the scattering of the flying fragments at a more dangerous height than when the shells burst from contact with the actual ground. The relation of one or two examples of wounds from pom-pom fragments may not be without interest, the more so as they illustrate the favourable influence of a low degree of velocity on the part of a projectile. I saw three wounds produced by the percussion fuses of these shells, an experience which shows that they were not very uncommon. [Illustration: FIG. 93.--Fragments of Vickers-Maxim 1-lb. Shells. The centre fragment of the lower row is the point of a steel armour-piercing shell; although unsuitable for the purpose, they were occasionally employed in the field by the Boers] (211) _Perforating shell-wound of abdomen._--Wounded at Magersfontein by the fuse screw of a small shell (Vickers-Maxim). Aperture of entry ragged, roughly circular, and 2 inches in diameter, with much-contused margins situated in the median line, nearly midway between the ensiform cartilage and umbilicus. The screw was lodged in the abdominal wall at the margin of the thorax, just outside the left nipple line. The aperture of entry was cleansed by Major Harris, R.A.M.C., who determined the fact that penetration of the peritoneal cavity had occurred, and removed the fuse (see fig. 94) by a separate incision. The patient made an uneventful and uninterrupted recovery, the wound healing by granulation and leaving little weakness of the abdominal wall. He returned to England at the end of five weeks. In a second case the fuse, together with a fragment of the iron case, entered the buttock by a ragged opening. The fragment of iron escaped by an exit aperture of about the same size. When the patient arrived at the Base some days after the injury, a hard body was felt in the wound, and on exploration the fuse was found and removed. In a third case the fuse struck the side of the foot below the outer malleolus and comminuted the astragalus, and then passing forwards lodged beneath the extensor tendons of the toes. The wound was explored at the time of the injury and some fragments of bone removed; considerable cellulitis supervened, and the fuse was only discovered some days later when the patient came under the care of Sir W. Thomson in the Irish Hospital in Pretoria. It was there removed, together with some more fragments of bone, and the wound slowly granulated. The patient then returned to England, when the wound rapidly healed after the removal of some further necrosed fragments of cancellous tissue. The astragalus had been reduced to a mere shell of compact tissue, and the convexity of the articular surface was altogether lost. The deformity, together with the formation of adhesions in the ankle-joint, led to the development of a firm anchylosis. [Illustration: FIG. 94.--Pom-pom Percussion Fuse, exact size] My friend Mr. Abbott removed a similar fuse from the substance of the lung after the lapse of nine months, the patient having developed an empyema, and a chronic fistula, which rapidly closed after the removal of the foreign body. [Illustration: PLATE XXV OBLIQUE FRACTURE OF THE HUMERUS CAUSED BY A FRAGMENT OF A VICKERS-MAXIM OR POM-POM SHELL The entire absence of comminution is very striking] I will add one further case, that illustrated by plate XXV. In this a fragment of a pom-pom shell entered the outer aspect of the right shoulder to escape on the inner aspect of the arm, just below the confines of the axilla. An oblique, non-comminuted fracture of the humerus resulted, which in spite of moderate suppuration united well in the course of six weeks. The case is of particular interest as illustrating the nature of the fracture to be expected when the velocity retained by the missile is low. The above instances show that such peculiarities as belong to wounds produced by pom-pom shells depend on the comparatively small size and weight of the fragments, and on the small degree of impetus with which they are propelled. [Illustration: FIG. 95.--Boer Segment Shell, or Shrapnel. The large fragment is a piece of the case, the smaller are two of the pieces of iron packed within] Fig. 95 illustrates a form of shrapnel employed by the Boers, the case of which is of cast metal arranged in definite segments, while the interior is filled with small fragments of iron so shaped as to pack in concentric layers. As to the wounds produced by the contained fragments I have no experience, since I never saw one of the pieces of iron removed. This no doubt depended in part on the very unsatisfactory practice made by the Boers with shrapnel generally. Even when they fired English shrapnel, the shells were, as a rule, exploded far too high to cause any serious danger to the men beneath. I saw on one occasion a large number of shrapnel shells exploded over a body of Imperial Yeomanry, but as a result of the great height at which all the shells were exploded, not a single casualty resulted. The segment casing of the shell, however, I several times saw removed from the body. The fragment shown in fig. 95 was removed from the buttock of a man after one of Lord Methuen's early battles. It may be remarked that the buttock is rather a common, and also a favourable, seat for shell wounds with retention of the fragment. This no doubt depends on the fact that the buttock is one of the few superficial regions in which sufficient depth of tissue exists for the retention or the passage of so large an object as a fragment of shell. Fig. 96 is of a number of leaden shrapnel bullets from our own shells. A normal undeformed bullet, such as was the usual cause of wounds, is shown at the left-hand upper corner. The remainder show common forms of deformity caused by striking on the ground or against rocks. I attribute small importance to the deformed bullets, as I never saw one removed, and it is probable that a ricochet shrapnel bullet would rarely retain sufficient force to penetrate. The lower fragments are inserted to illustrate a fact that would scarcely have been assumed, that these bullets on impact occasionally suffer a fracture of a somewhat crystalline nature. The occurrence of this gross form of fracture is of some interest in relation to the extreme fragmentation sometimes undergone by the hardened leaden cores of the small-calibre bullets. A considerable number of wounds from leaden shrapnel bullets were met with among our own men, as well as among the Boers. The wounds possessed little special interest, except from the fact that the bullets were often retained. I saw bullets in the chest on several occasions, also in the abdomen, pelvis, the neighbourhood of joints, and in the limbs. I saw one patient who had suffered no less than six perforating wounds as the result of the bursting of one shrapnel shell. I will here quote one case of interest as completing the various forms of perforating wound of the abdomen met with during the campaign. [Illustration: FIG. 96.--Normal, Deformed, and Fractured Leaden Shrapnel Bullets] (212) _Perforating shrapnel-wound of abdomen._--Boer wounded at Graspan. Aperture of _entry_ (shrapnel), opposite eighth left costal cartilage, 1 inch external to nipple line. The opening was circular, and surrounded by an area of ecchymosis 4 inches in diameter; _exit_, 4-1/2 inches above and to the right of the umbilicus. Patient was at first in a Boer ambulance, and only seen by me on the ninth day. At that date he was dressed and walking with a gauze pad and bandage over the wounds. From the exit wound, which was 1 inch in diameter, protruded a piece of sloughing omentum, the margin of the wound being everted and raised over a circular indurated area. It was thought best to allow the sloughing omentum, which was very foul, to separate spontaneously, and then to return the stump. At the end of three weeks, however, the slough had not only separated, but the stump had retracted, and only a small granulating surface was left, which healed spontaneously. I have little to say regarding the treatment of shell wounds. The mutilating injuries, if not of a fatal character, necessitated treatment of a corresponding nature to the damage. In all such cases the general rules of surgery indicate the lines to be followed. In the case of shrapnel wounds the bullets were often better removed; but when in dangerous positions, as sunk deeply in the chest, abdomen, or pelvis, they were best left, unless some very special indication for removal existed. Large fragments of shell always demanded removal. In conclusion I will only make the further remark, that shell wounds, with the exception of clean leaden shrapnel tracks, always suppurated. I make this closing statement with the view of emphasising the influence exerted on the aseptic course of modern rifle wounds by the small calibre of the bullet, since both bullet and shell wounds were exposed to the same surrounding conditions. INDEX Abdomen, injuries to, 407 General prognosis in, 470 Abdominal wounds: Explosive, 414 Non-perforating, 409 Perforating, 411 Abscess of the brain, 287 Acetabulum, fracture of, 193 Acetylene light, 30 Ambulance: Foreign, 30 Trolly (McCormack-Brook), 18 Wagons, 19 Amputations: Effect of transport on, 110 for fracture, 177 Aneurisms: Effect of rest on, 127 Gangrene after, 152 Traumatic, 122 False, 123 True, 126 Treatment of, 127 Aneurismal varix: Arm and forearm, 147 Effect on circulation, 134 Carotid, 146 Femoral, 147 Mode of development, 130 Popliteal, 147 Prognosis in, 144 Signs of, 131 Treatment of, 144 Anosmia, 348 Antrum, wounds of, 306 Aphasia: Amnesic, 276 Ataxic, 273 Functional, 351 Arterial hæmatoma, 123 Prognosis in, 126 Treatment of, 126 Arteries: Compression by cicatrices, 113 Contusion of, 112 Division of, 114 Perforation of, 114 Arterio-venous aneurism: Arm and forearm, 150 Cervical, 149 Femoral, 150 Leg, 150 Popliteal, 151 Treatment of, 148 Biliary fistula, 467 Bladder: Wounds of, 443, 457 Extra-peritoneal, 458 Intra-peritoneal, 457 Retained bullet in, 110, 460 Bones. See Fractures Bowlby, Mr.: Retained bullets in joints, 229, 230 Wound of pharynx, 311 Brain: Abscess of, 287 Cerebral irritation, 269 Compression of, 267 Concussion of, 266 Effect of ricochet on, 249 Explosive injury of, 247, 248 Frontal injuries, 247, 249, 266 Fronto-parietal injuries, 273 Occipital injuries, 276 Parietal injuries, 273 Prognosis in cerebral injuries, 289 Treatment, 289 Bread, 7 Buck wagon, 21 Bullets: Characters directly affecting wounds: Aseptic nature, 70 Calibre, 41 Composition of, 51 Deformities of, 81 Fragmentation, 88 Length, 41 Mantles of, 52, 82, 83 Penetration, 49 Revolution, 45 Ricochet, 82 Shape, 42 Stability, 51 Striking force, 50 Velocity of flight, 42 Weight, 42 Effect of resistance of bones on, 86, 87, 88, 93 Retention of, 71, 79 Indications for removal of, 110 in bladder, 110, 460 in chest, 381, 401 in nasal fossa, 244 in or near joints, 229, 230 in skull, 244, 249, 260, 266, 284, 298 in spinal canal, 337 Reversal of, 81 Varieties of: Determination of, 105 Expanding, 91 Explosive, 95 Guedes, 48, 51 Krag-Jörgensen, 48, 51 Jeffreys, 94 Large leaden, 95 Lee-Metford, 52, 89 Mark IV., 94 Mauser, 52, 83 Soft-nosed, 93 Tampered, 95 Tweedie, 94 Waxed, 52 Cauda equina, injury to, 325, 330 Cellulitis, 34 Cervical nerve roots, injury to, 107 Plexus, 357 Cheatle, Mr. G. L.: Entry and exit wounds, 72 First field dressing, 107 Wound of heart, 383 " " intestine, 413 Cheek, wounds of, 309 Chest, injuries to, 374 Character of wounds, 377 Influence of small calibre of bullet on, 374 Martini wounds, 374, 388 Non-penetrating wounds, 375 Penetrating wounds, 376 Cheyne, Mr. W. W., F.R.S.: Abdominal wounds, 449 Spent bullets, 243, 449 Civil surgeons, 38 Climate, 8, 36, 71 Comparison of South African with other campaigns, 14 Compression of brain, 267 Spinal cord, 319 Concussion of brain, 266 Eye, 300 Joints, 226 Nerves, 341, 343 Spinal cord, 315 Contour wounds, 65 Contusion: Nerves, 343 Spinal cord, 316 Costal cartilages, fractures of, 379 Cox, Dep. Insp.-Gen.: Case of varix, 148 Day, Mr. J. J.: Fractures of the skull, 251 Deadliness of modern weapons, 16 Diaphragm, wounds of, 381 Displacement of structures by the bullet, 68 Abdomen, 411 Nerves, 342 Vessels, 382, 384 Viscera, 310, 382, 411 Drink, 8 Dust, 8, 35 Bacteriology of, 36 Empyema, 394, 396 Enteric fever, 9 Epilepsy, traumatic, 291 Equipment of foreign ambulances, 31 Surgical, 4 Erysipelas, 34 Expanding bullets, 91 Explosive bullets, 95 Explosive wounds: of abdomen, 414 of fractures, 155 of head, 245 of leg, 221 of soft parts, 97 of thigh, 197 Eye, injuries to, 299 Facial paralysis: Cortical, 273-277 Peripheral, 355 First field dressings, 107 Flies, 36 Flockemann, Dr.: Hæmothorax, 393 Injury to abdomen, 420 Fractures: Course of healing of, 172 Explosive wounds in, 155 into joints, 163, 228 Limb bones, 154 Local shock in, 172 Long bones, types of, 161 Longitudinal, 163 Notch, 165 Oblique, 165 Perforating, 166 Stellate, 161 Transverse, 166 Wedge, 165 Osteomyelitis in, 174 Pom-pom fractures, 483 Prognosis, general, in, 174 Special features of, 155 Special bones: Acetabulum, 193 Carpus, 183 Clavicle, 178 Femur, 193 Fibula, 219 Humerus, 178 Jaws, 306 Malar, 305 Mastoid process, 299 Metacarpus, 185 Metatarsus, 224 Orbital walls, 300 Patella, 215 Pelvis, 189 Radius, 183 Ribs, 377 Scapula, 177, 379 Skull: Base, 262 Glancing, 254 Gutter, 255 Perforating, deep, 245 Superficial, 259 Treatment of, 293 Spine, 314 Sternum, 379 Tarsus, 223 Tibia, 217 Short and flat bones, 168 Suppuration of soft parts in, 173 Symptoms of, 171 Treatment of: General, 175 Femur, 205 Leg, 221 Upper Extremity, 135 Variation in character during the campaign, 154 Fractures in Franco-German war (Sir W. MacCormac), 167 Fragmentation of bullets, 88 Fuses of shells, wounds by, 481 Gangrene: Acute traumatic, 34 After ligature of main vessels, 152 Genital organs, wounds of, 472 Guedes rifle, 65 Gutter wounds: of bladder, 458 of bones, 231 of intestine, 417 of joints, 231 of liver, 466 of pelvis, 189 of scalp, 242 of skull, 255 of soft parts, 157 Hæmarthrosis, 232 Hæmorrhage, 104, 114 Control by bullets, 116 by loop of nerve, 116 Deaths from, 116 Fever dependent upon, 118 Internal, 116 Interstitial, 118 Primary, 114 Recurrent, 117 Secondary, 117 Treatment of, 120 Hæmorrhoids, 10 Hæmothorax, 386, 389 Behaviour of blood in, 390 Course of, 390, 394 Diagnosis of, 398 Effect of transport on, 389 Empyema after, 394 Pleuritic effusion in, 390 Prognosis in, 399 Recurrent bleeding in, 393 Parietal, 389, 398 Pulmonary, 386, 389 Symptoms of, 391 Temperature in, 391, 393 Treatment of, 400 Head, injuries to, 241 Health of the troops, 7 Heart, wounds of, 382 in neighbourhood of, 384 Hemianopsia, 276 Altitudinal, 277 Lateral, 276 Hospitals: Field, 29, 37 Foreign, 30 General, 31, 38 Improvised, 28, 39 Indian Field, 29 Stationary, 27, 31, 33, 37 Varieties of, 28 Hospital ships, 24 Tents, 32 Trains, 23 Hydronephrosis, 464 Impact, irregular, 80, 82 Instruments, 4 Intestine, injuries to: Diagnosis of, 428 Difficulties of operation, 453 Indications for operation, 454 Lateral contusion, 416 Prognosis, 446 Treatment, 452 Wounds of, 415 Extra-peritoneal, 419 Large intestine, 436, 444 Results of, 421 Small intestine, 427 Irregular wounds, 97 Itinerary, 2 Jam, 7 Jaws, fractures of: Lower, 306 Upper, 306 Treatment of, 308 Jenner, L. L., bacteriology of dust, 36 Joints, injuries to, 225 Arterial wounds in, 121, 233 Classification of, 229 Course after, 232 Fractures into, 228 Signs and symptoms, 232 Suppuration of, 233 Treatment, general, 235 Joints, retained bullets in or near, 229, 230 Joints, special: Ankle, 239 Elbow, 236 Hand, 237 Hip, 238 Knee, 238 Shoulders, 236 Tarsus, 240 Ker, J. E., cases of aneurism, 152 Kidney, wounds of, 461 Krag-Jörgensen rifle, 65 Laminectomy, 335, 340 Larynx, wounds of, 312 Leaden bullets, 95 Lee-Metford rifle, 53, 64 Lewtas, Col. I. M. S., cases of aneurism, 144 Lightning stroke, 10 Liver, wounds of, 466 Local shock, 103 in fractures, 172 Lower jaw, fractures of, 306 Lungs, wounds of, 385 Diagnosis, 398 Effect of velocity on, 385 Prognosis, 399 Retained bullets in, 401 Symptoms of, 386 Treatment of, 400 Lyddite shells, 475 MacCormac, Sir W.: Aneurism, 150 Fractures, 167 Malar bone, fractures, 305 Mandible, fractures, 306 Mantles, stability of, 51, 83 Martini-Henry rifle, 48 Wounds by, 96 Mastoid process, 299 Mauser rifle, 64 Meat, 7 Mediastinal wounds, 382, 384 Mesentery, wounds of, 420 Mills-Roberts, Mr. H. R.: Spinal hæmorrhage, 321 'Modders, the,' 9 Mortality, general, 11 amongst officers, 14 in battles of Kimberley Relief Force, 12 Nasal _fossæ_, bullet in, 244 Neck, wounds of, 309 Nerves, injuries to, 341 Concussion, 341, 343, 346 Contusion, 343, 347 Displacement of, 342 Laceration, 344, 348 Perforation, 345 Prognosis in, 370 Scar, implication of, 345, 350 Section, 344 Symptoms of, 346 Treatment of, 371 Velocity in relation to, 341 Nerves, special: Cranial: Fifth, 353 Fourth, 353 Eighth, 353, 354 Eleventh, 356 Olfactory, 352 Optic, 352 Seventh, 354, 372 Sixth, 353 Tenth, 356 Third, 353 Twelfth, 357 Spinal: Brachial, 357 Cervical, 347, 357 Lumbar, 359 Sacral, 359 Sacro-coccygeal, 360 Thoracic, 358 Neuritis: Ascending, 350 Peripheral, 355 Traumatic, 349 Neurosis, traumatic 351 Nose, wounds of, 305, 348 Nurses, 38 Officers, mortality among, 14 Olecranon, fracture of, 183, 237 Omentum, wounds of, 420 Prolapse of, 420 Operations: Difficulties of, 35 in field, 296 in Field hospitals, 109 Orbit, wounds of, 299 Prognosis and treatment of, 304 Osteomyelitis in fractures, 174 Outfit, surgical, 3 Pain in wounds, 103 Paraplegia, functional, 337 Penetration of bullets, 49 Penis, wounds of, 472 Peritoneal infection, 412 Pharynx, wounds of, 311 Pleural septicæmia, 437 Pleurisy, 390, 398 Pneumonia, 9, 398 Pneumo-thorax, 388 Pom-pom shells, 478 Portland Hospital, 34 Psychical disturbance, 101 Rain, 9, 36 Range of fire: Difficulty of judging influence on mortality, 17 Rectum, wounds of, 443, 444 Removal of wounded from the field, 18 Respiration in spinal injuries, 329 Retained bullets. See Bullets Reversed bullets, 81 Revolution of bullet, 45, 46 Ribs, fractures of, 377 Signs of, 379 Ricochet, 82 Effect on wound type, 249 Lee-Metford, 89 Mauser, 84 Within body, Abdomen, 415 Skull, 249 Rifles: Bore, 41 Guedes, 47, 54 Krag-Jörgensen, 47, 54 Lee-Metford, 47, 64 Martini-Henry, 47, 97 Mauser, 47, 64 Modern principles of, 40 Trajectory, 44 Varieties employed, 47, 48 Scalp wounds, 242, 264 Scapula, fractures of, 177, 379 Scrotum, wounds of, 472 Septic disease, 34 Septicæmia: General, 34 in enteric fever, 9 Peritoneal, 421 Pleural, 437 Shells, 474 Varieties of, 475 Vickers-Maxim, 478 Lyddite, 476 Shrapnel, 483 Shell wounds: of abdomen, 480, 485 Proportionate occurrence of, 11 Shell fuse wounds, 481 Ships, hospital, 24 Shock: General, 101 Local, 103 Treatment of, 110 Shrapnel, 483 Simla, 25 Skull. See Fractures Fractures independent of gross brain lesion, 242 with brain lesion, 248 Spinal column: Injuries to, 314 Fractures of centra, 317 Spinous processes, 315 Transverse processes, 314 Spinal cord, injuries to, 315 Compression by bullets, 319 Concussion, 319 Contusion, 320 Diagnosis, 335 Hæmato-myelia, 322 Section of, 323 Shock accompanying, 328 Signs of, 323 Transport of, 339 Treatment of, 339 Spinal hæmorrhage: Epidural, 321 Hæmato-myelia, 322 Peri-pial, 321 Spleen, wounds of, 469 Splints: Aluminium, 177 Field cane, 209, 221 Hodgen's, 211 Wire gauze, 187 Sternum, fractures of, 379 Stevenson, Col. W. F.: Local shock, 106 Explosive wounds, 159 Stokes, Sir W.: Treatment of aneurism, 151 Stomach, wounds of, 424 Stonham, Mr. C.: Wound of vermiform appendix, 437 Sunstroke, 10 Suppuration of wounds, 78 in fracture, 173 Synovitis, vibration, 226 Temperature of air, 8, 36 in blood effusions, 118, 391, 393 Tents, 32 Testicle, wounds of, 472 Tetanus, 34 Thirst, 8 Thomson, Sir W.: Pom-pom wounds, 479 Wound of nose, 305 Thoracic vessels, wounds of, 384 Tonga, the, 19 Tongue, wounds of, 309 Trachea, wounds of, 312 Traction engines, 23 Trains, hospital, 23 Trajectory, 44 Transport: after battles, 26 of wounded men from field, 18 of wounded of the Kimberley Relief Force, 25 of chest injuries, 386 of fractures, 176 of spinal injuries, 339 Traumatic aneurism. See Aneurism Traumatic epilepsy, 291 Traumatic gangrene, 34 Traumatic neurosis, 107, 351 Treves, Mr. F.: on cessation of intestinal peristalsis, 423 Trolly (McCormack-Brook), 19 Upper jaws, 306 Urethra, wounds of, 472 Urinary Bladder. See Bladder Varix. See Aneurismal varix Vegetables, 7 Veldt sores, 10 Velocity of bullet: Circumstances influencing, 43 Initial, 42, 49 Remaining of various rifles, 49 Velocity, influence of: on fractures of long bones, 163 on fractures of short and flat bones, 168 on wounds of abdomen, 414 of chest, 385 of joints, 226, 230 of lungs, 385 of nerves, 341 of skull, 251 of spine, 319 Vermiform appendix, wounds of, 437 Vibration synovitis, 226 Vickers-Maxim shell, 478 Vomiting in spinal injuries, 329 Wagons: Ambulance, 20 Buck, 22 Ox, 20 Warfare, deadliness of, 40 Water in South Africa: Character of, 8, 36 Transport of, 5 Waxed bullets, 52 Wobble, 80, 81, 251 Wounded men, removal from the field, 18 Wounds, general: Aperture of entry, 55, 72 Aperture of exit, 58, 74 Climate, influence on, 71 Clinical, course of, 69 Contour tracks, 65 Direct nature of tracks, 63 Directions of tracks, 66 Displacement of structures, 68 Explosive exit wounds, 97 Foreign bodies in, 71 First field dressing, 107 Hæmorrhage, 104 Irregular types of, 80, 97 Mode of healing, 72 Multiple character, 67 Nature of tracts, 68 Pain, 103 Prognosis, 106 Psychical disturbance, 101 Shock, 101 Small bore, 67 Superficial tracts, 65 Suppuration, 69, 78 Symptoms, 100 Tracks, nature of, 68 Treatment, 107 * * * * * PRINTED BY SPOTTISWOODE AND CO. 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