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AMERICAN ADDRESSES 
 
 BY 
 
 SIR BERKELEY MOYNIHAN, M.S., F.R.C.S. 
 
 ' s:t^ ' 
 
 PHILADELPHIA AND LONDON 
 
 W. B. SAUNDERS COMPANY 
 
 1917 
 

 Copyright, 1917, by W. B. Saunders Company 
 
 
 PRINTED IN AMERICA 
 
TO 
 
 G. W. CRILE 
 
 £ 
 
 <2L 
 
PREFACE 
 
 The papers included in this volume were read in 
 Chicago and elsewhere during October and Novem- 
 ber, 1917. I hope they may help my American col- 
 leagues to some appreciation of the causes and 
 conditions of the war, and afford some help to them 
 in their treatment of the many new phases of surgical 
 diseases with which they will be called upon to deal. 
 
 The papers represent not only my own views and 
 experience, but those of others also. In forming 
 my opinions upon the several matters discussed I 
 have received very great help from the many con- 
 sultations and discussions I have had with many of 
 my friends in the different war zones of France and 
 England. I may most appropriately and appreci- 
 atively quote — 
 
 "I have gathered a posie of other men's flowers 
 And nothing but the thread that binds them is mine own." 
 
 Berkeley Moynihan 
 
 November, 1917 
 
CONTENTS 
 
 PAGE 
 
 The Causes of the War 11 
 
 Gunshot Wounds and Their Treatment 33 
 
 Wounds of the Knee-joint 73 
 
 On Injuries to the Peripheral Nerves and Their 
 
 Treatment 89 
 
 Gunshot Wounds of the Lungs and Pleura 117 
 
AMERICAN ADDRESSES 
 
 THE CAUSES OF THE WAR 
 
 CONVOCATION ADDRESS TO THE AMERICAN COLLEGE 
 OF SURGEONS 
 
 "How happy is he born or taught. 
 That serveth not another's will; 
 Whose armour is his honest thought. 
 And simple truth his utmost skill!" 
 
 What is this war about? How has it come about 
 that America and England are standing side by side 
 in SO bitter and stern a conflict against Germany and 
 Austria? What are the strange circumstances which 
 at last have ranged against the Central Powers of 
 Europe almost all the free peoples of the world? 
 
 No doubt many answers, each conflicting with the 
 rest, and yet each containing some small grain of 
 truth, may be given to these questions. We may say, 
 for example, that we fight against the continued ag- 
 gression of Prussia and those other German and 
 Austrian powers whom Prussia has inspired and in- 
 stigated. No one who reads history with an unbiased 
 mind can doubt that Prussia has increased, often 
 if not always, at the expense of other states by acts 
 
 11 
 
12 AMERICAN ADDRESSES 
 
 of sudden and unprovoked aggression. Certainly, 
 from the hour when, in the midst of peace, Prussia 
 laid rude and violent hands upon Silesia, her own 
 aggrandisement, her territorial increase, and her 
 growth in power and possessions outside her own 
 borders, have been due to the wars she has waged. 
 War is the National industry of Prussia; it is her 
 means of acquiring wealth ; it is by her military suc- 
 cesses that she has enlarged her borders, added to her 
 own infertile lands, solidified her gains, and been 
 able to prepare for a still further attack upon her 
 next chosen victim. States may advance in power, 
 and in all that power implies, in wealth and pros- 
 perity, and in the happiness of its citizens, by ac- 
 quisition from without, or by growth from within, 
 by discovery and development of its own resources, 
 and by directing all the energies and talents of its 
 people to its own internal advancement. No state in 
 history can compare with Prussia in its exploitation 
 of the doctrine of plunder; the doctrine of taking 
 because it has the power, and of keeping because it 
 has the strength to do so. Quite consciously and quite 
 unabashed she has possessed and gloried in the pos- 
 session of this power, has fostered it, and with de- 
 liberate and frank intention has exerted it at her 
 own time and for her own ends. She sought dominion. 
 
THE CAUSES OF THE WAR 13 
 
 she had her own confident and unwavering conviction 
 of her power to seize it, and of all the means by which 
 it was firmly to be held. From her point of view she 
 had every reason to think her methods were right. 
 Not for one instant, of course, did she call in question 
 the principles, or doubt the ideals, which underlie her 
 action. The Greatness of Prussia, the Dominion of 
 Prussia, which grew at last into the lust for World 
 Dominion by Germany, were embedded deep in the 
 very fabric of the Prussian mind. Perhaps not so 
 much embedded as incorporated, distributed, that 
 is, equally land generously through every part of her 
 national consciousness. The successes of 1864, 1866, 
 1870 are, even at this long distance of time, stupen- 
 dous not so much in their material results, remarkable 
 as these were, but in their disclosure of a mighty and 
 well-ordered power that seemed to move irresistibly 
 along a predestined path, to a goal which had been 
 long foreseen and calmly and securely chosen. Never, 
 it is safe to say, in warfare before had plans been so 
 carefully laid, never had they matured in more per- 
 fect accord with such design. In this war also we 
 learned without surprise that the official communique, 
 published in Berlin in the first weeks of the war, told 
 with laconic precision that '* everything proceeded 
 according to plan." If anything on earth was in- 
 
14 AMERICAN ADDRESSES 
 
 fallible, surely, said the German nation, our army 
 and its leaders are infallible. The motive of the war, 
 if this answer were true, would be Germany's am- 
 bition. 
 
 Or, we may answer my question differently. We 
 may say that Germany had grounds for her belief 
 that she was a nation encircled by hostile powers, 
 jealous of her splendid growth, of her swift acquisi- 
 tion of wealth, of that armed strength afloat and 
 ashore, to which she added daily. And we may listen 
 to her passionate utterance that her access to blue 
 water was barred, her commerce crippled, that she 
 was denied that "place in the sun" to which her 
 might entitled her. We can understand Germany, 
 though we cannot for one instant agree with her 
 when she says that for her this was a war of defence, 
 that she is fighting for a way out of the strong iron 
 bastion that had been built up around her frontiers. 
 Prussia in her early days never had a frontier, and 
 her first conscious act as a nation was to forge out 
 of her army the frontier which nature had denied to 
 her. The motive of the war, if this answer were true, 
 would be Germany's fear: fear, the black godmother 
 of cruelty. 
 
 These are the conflicting answers that may be 
 given by one side or the other. But anyone who has 
 
THE CAUSES OF THE WAR 15 
 
 given thought to the matter (and who has not?) must 
 agree that whatever else this ghastly conflict now is, 
 it is in simple truth, not a clash of merely material 
 interests. This is a moral war. It is a holy war if 
 ever there was one. It is deep down a war between 
 conflicting and discordant and unconformable moral 
 systems. It is a war, therefore, in which a real peace 
 cannot come by compromise; for you cannot come to 
 any terms but one, with that which you feel to be a 
 principle of evil, with that which you feel in your in- 
 nermost soul to be the deadliest enemy to mankind, 
 and the most menacing blight with which civiliza- 
 tion has ever been threatened. 
 
 What then are the issues at stake .^^ How is the 
 question I put to be answered.^ 
 
 Let us examine the principles which appear to 
 underlie the action of the protagonists in this very 
 whirlwind of war. The principle ground into the 
 very fibre of the German peoples, accepted by them, 
 gloried in by them, worshipped by them, inspiring 
 them, is the principle of Tyranny. What exactly is 
 meant by that? It implies a complete surrender of 
 individual rights and liberties, and an unquestioning 
 submission of them to a power exercised exclusively 
 from without. This power may be called the State, 
 or the Dynasty, or it may be a ruling caste. It is 
 
16 AMERICAN ADDRESSES 
 
 something outside and above the individual, uncon- 
 trolled by him, owning no allegiance to him, but di- 
 recting him and ordering all his actions in a manner 
 and with a purpose which, he is told, are for the benefit 
 not onl}^ of the paramount authority, but incidentally 
 or consecutively of himself. Tyranny, that is to say, 
 is the power exercised by an irresponsible autocracy; 
 it is the supremacy of the State carried to its ultimate 
 expression; and it is by implication an attribute of 
 every individual in the State. This is no ignoble 
 creed, and Prussia, let us tell it to her credit, has made 
 a robust philosophy of it, and has gained the staunch 
 and willing adhesion to it of almost every man in her 
 nation. Vigour and efiiciency are the practice of this 
 creed; that "might is right" is the law by which it 
 lives; courage is its inspiration; in success is found 
 its ample apology. Treitschke tells us in terms that 
 cannot be misunderstood that the "State is Power," 
 and that nothing can conflict with the State's duty 
 to uphold and extend itself by the exercise of might. 
 This is in truth the "Religion of Valour." 
 
 Over against this what have we to set up, on our 
 side, as our standard? What is the principle by 
 which we are sustained .^^ whence do we derive our 
 soul's refreshment.'^ It is hard to find the precise 
 word, but none fits so well as Liberty. And by liberty 
 
THE CAUSES OF THE WAR 17 
 
 we mean here the inahenable and indestructible right 
 of every human being to express himself, to be him- 
 self, to develop from within. The relationship of a 
 man endowed with, and encompassed by, such lib- 
 erty, to the State is simple enough. The laws which 
 govern and control him are laws which he himself 
 has helped to make, and to which he, with others like 
 him, willingly conforms, not so much because the laws 
 are good, but because they are laws which he, and 
 those who have gone before him, have in freedom, 
 imposed upon themselves. This is democracy. To 
 us as surgeons practising a scientific profession the 
 conflict between these irreconcilable principles is of 
 deep significance. For let us consider their applica- 
 tion to education. 
 
 Tyranny, in the sense in which I have used it, 
 means that every unit in the nation must receive an 
 imprint, a stamp from the State, indicating his train- 
 ing and value. The doctrine of tyranny implies that 
 for the service of the State every individual must 
 receive such training as will fit him to be, and ensure 
 his becoming, a willing and obsequious servant of 
 the State. This necessarily implies the possession, 
 or the capture by the State, of all the machinery of 
 education. Is this, in fact, what has happened in 
 Prussia and in Germany.? There can be no doubt 
 
 2 
 
18 AMERICAN ADDRESSES 
 
 whatever about the answer. The German educa- 
 tional machine is an absolutist machine, a possession 
 of the central authority, exactly as is the navy or the 
 army. Bismarck said, on August 11, 1893: "The 
 school is an important part of Germany's national 
 institutions. The German school, like the German 
 corps of officers, is a specifically German institution 
 which no other nation can easily copy. In the course 
 of the last few decades the seed sown by the schools 
 among the youth has borne fruit and has given us a 
 national political consciousness which formerly we 
 lacked. The most potent influence which the body 
 of the teachers brings to bear upon German national 
 education consists in this, that when the German 
 teacher receives the child its mind is like a white 
 sheet of paper. What the teacher writes on it is 
 written with indelible ink. It remains for life. The 
 youthful soul is soft and receptive, and we all know 
 that we never forget what we have been taught be- 
 tween the ages of seven and fifteen years. The 
 lessons then impressed upon us guide us forever. 
 In this receptivity of youth, in the fact that the minds 
 of people may at an early age be molded for all time, 
 lies the power which the German teachers have over 
 Germany's future. As I have said on a former occa- 
 sion, he who controls the schools controls the future." 
 
THE CAUSES OF THE WAR 19 
 
 Education in Germany may be obtained in pub- 
 lic or in private institutions. The last figures avail- 
 able showing the number of students attending Ger- 
 man schools are for the year 1911. ,In that year there 
 were 11,050,620 pupils in public schools, as against 
 126,278 in private schools — a proportion of 88 to 1. 
 In Prussia alone the numbers were 6,674,989 in pub- 
 lic schools to 8996 in private schools — a proportion 
 of nearly 750 to 1. The importance of this gigantic 
 difference is realised when it is understood that the 
 teachers in the public schools "have the rights and 
 duties of State officials"; that is, they may prune 
 themselves with all the petty arrogance which is 
 inseparable from a Teutonic official, but they must 
 submit to that iron discipline which regulates their 
 conduct, and must curry favour with that stern and 
 unbending authority upon which their academic 
 career entirely depends. And this firm and unrelenting 
 grip fastens also upon the universities and upon every 
 professor. None can hope for promotion, or for those 
 titles and distinctions which are so precious, unless he 
 is in all essential things in agreeable conformity with 
 those who exercise control. "No scientist, however 
 eminent, can hope to obtain a professorship in Prussia 
 if he is persona ingrata with the government, and 
 a professor who opposes the government, unless he 
 
20 AMERICAN ADDRESSES 
 
 acts, with the greatest moderation and circumspec- 
 tion, is likely to lose his position and income." The 
 German government exercises practically unlimited 
 influence over the universities rather by indirect 
 than by direct means. The university professors can 
 be controlled or cajoled by the Minister of Educa- 
 tion, who exercises vast powers and distributes a 
 valuable patronage. All of us know how influences 
 of this kind may be wielded, and how swift and heavy 
 may be the visitation for a grave offence. 
 
 The State, then, in Germany not only owns the 
 educational establishment, but elects and trains the 
 teachers in the several grades of schools, confers upon 
 them the rights, and exacts from them the duties, of 
 State officials, and finally exerts a firm and purpose- 
 ful direction upon the instruction given to all pupils. 
 For its own objects the State uses the didactic weapon 
 with a strong hand and a far-seeing and ruthless pur- 
 pose, and she makes no secret of her intentions. The 
 Kaiser himself, in an educational address, has said, 
 speaking of the use of the school as a political weapon : 
 "If the school had done what must be demanded of it, 
 it should at once and on its own motion have under- 
 taken the fight against social democracy. The teach- 
 ing boards ought to have combined and ought with 
 energy to have instructed the growing generation in 
 
THE CAUSES OF THE WAR 21 
 
 such a manner as to furnish me with material with 
 which I can work within the State. Then it would 
 have been easy to overmaster quickly the Socialist 
 movement"; and again: "Men who support Radical 
 Utopias can as little be employed in education as they 
 can be employed in the government offices"; and 
 that this view of the duty of the State to use this in- 
 strument still continues we have the authority of 
 Friedel, who states that today "both the Prussian 
 government and the Imperial Government of Ger- 
 many were stealthily taking every step towards a cen- 
 tralization of control of German education in order 
 that under the political influences of the Imperial 
 Government every school, every university, and every 
 educational outpost of Germany after the war might 
 respond at once to instructions from the centre, 
 and use their intellectual propaganda for Germanic 
 ends." German education, both before the war and 
 since the war began, has indeed been a master weapon 
 in the hands of the military party, and there is, as 
 we learn without surprise, every intention that the 
 strength of this implement shall be used as ruthlessly 
 as ever in the service of the State. There is evidence, 
 M. E. Sadler tells us, — and there is no better in- 
 formed authority, — that in Germany there has re- 
 cently been a huge wave of national feeling expressing 
 
22 AMERICAN ADDRESSES 
 
 itself in demands for emphasis upon those subjects 
 which would fill the minds of boys and girls with a 
 sense of glory in the German past, of confidence in the 
 German future, and with some contempt for Ger- 
 many's enemies. These efforts are not restricted to 
 domestic matters. We know that measures are being 
 taken to extend the sphere of German influence, 
 through the medium of education, in Turkey, and the 
 Balkans, and in Latin South America, not only by 
 the government, but by the business men and by in- 
 structed public opinion. 
 
 This brief exposition of Germany's educational aims 
 does not attempt, or desire, to deny the many and great 
 achievements which can most justly be placed to their 
 credit. The average German student was well taught, 
 even if the things he learned were not always a sober 
 reflection of the truth; even if truth were held of less 
 account than expediency. A multitude of talents may 
 not inaccurately describe the German nation, con- 
 sidered from the educational standpoint. A nation so 
 organized and so instructed may, indeed, as all the 
 world has learned, be either a mightj^ influence for 
 good, or a strong and sinister implement of mischief. 
 "Opinion in Germany," says a well-informed and 
 credible writer, "from the cradle to the grave, has 
 been controlled and directed by the military, Macht- 
 
THE CAUSES OF THE WAR 23 
 
 politik, and the policy of ruthlessness in warfare is, 
 therefore, unanimously advocated by soldiers and citi- 
 zens, scientists and clergymen, merchants and Roman 
 Catholic priests." 
 
 This is, in my belief, a fair statement of the effect 
 of the principle of tyranny applied to educational 
 methods and propaganda. 
 
 The principle of liberty acts far otherwise. This 
 implies the desire and intention of those responsible 
 for the teaching of the nation that the individual 
 shall develop, morally or intellectually, from within; 
 that by education he shall be given the power and 
 enjoy the opportunity of self-development and learn 
 the manner of self-expression. Where Germany seeks 
 to nurture in each child the gifts, and the measure 
 of those gifts in so far as they may be of direct ser- 
 vice to the State, the system of liberty desires the 
 fullest development of all the natural powers in order 
 that in their own measure and stature they shall be 
 available for the common good. And so by the Ger- 
 man method instruction of the hard-and-fast kind 
 extends to all branches of learning. I remember well, 
 only a month before the war, discussing with a dis- 
 tinguished German colleague some aspects of English 
 literature and some gifts and qualities of the men who 
 had bequeathed to us the splendid heritage which is 
 
24 AMERICAN ADDRESSES 
 
 the chief glory shared by all who speak our common 
 tongue. I was struck not only by the variety, but 
 also by the rapidity of the judgments expressed. 
 When, for example, Galsworthy was mentioned, 
 there came a clear and crisp opinion, precise, uncom- 
 promising, devoid of qualification or of illustration. 
 I wondered at the swift precision until a few minutes 
 later we came to speak of Oscar Wilde. Now Wilde, 
 with all his subtly interwoven virtues and defects, 
 cannot be expressed in an epigram or summarised 
 and dismissed in a phrase. Yet in this case again I 
 had to listen to a curt and neat and exact survey of 
 Wilde's position among modern authors. I was lost 
 in stupefaction, but had the curiosity to ask if my 
 adversary in this friendly debate had read much of 
 Wilde's work. And quite frankly the confession was 
 made that not one volume of this author had been 
 read. The opinions to which I had listened with real 
 interest were, so I learned, those held in Germany, 
 taught in her schools, and humbly accepted as apt 
 and accurate. Even in a matter so remote from any 
 bureaucratic importance there was, so to speak, the 
 ofiicial and authoritative opinion. Here, as often 
 before, the German people would seem to hold a 
 "herd" opinion upon many problems, and to express 
 them in identical phrases. This little illuminating 
 
THE CAUSES OF THE WAR 25 
 
 experience seemed to me to have its own, and a very- 
 real, significance, and to contrast quite sharply with 
 what would have happened if I had been discussing 
 this matter with a fellow-countryman. He indeed 
 might never have read Wilde, though probably he 
 would have seen one of his most charming plays; 
 if he had read Wilde he might not have thought it 
 worth while to form an opinion about him as a writer 
 of English prose; but it is quite certain that if he 
 expressed an opinion it would be his own opinion, 
 whether right or wrong. "A small thing but mine 
 own" he might have said apologetically. 
 
 Is then the German system really educational.'^ It 
 is, I believe, a mistake to assume that the present 
 highly organised, well-planned, systematic instruc- 
 tion in the German schools really educates the Ger- 
 man people. It puts upon their minds too many 
 ready-made opinions, disposes them too easily to 
 accept the judgments of experts on subjects with 
 which they are not familiar; it departmentalizes Ger- 
 man opinion and prevents the ordinary German citi- 
 zen from forming his own judgment on the profound- 
 est political and moral issues while giving him an 
 overflowing consciousness of excellence. 
 
 The system of liberty, on the one hand, desires 
 rather to develop and strengthen the character of the 
 
26 AMERICAN ADDRESSES 
 
 future, citizen; the system of tyranny seeks to train 
 and stamp the intellect with a certain quality. It is 
 free natural growth, on the one hand; it is repressive 
 and specific culture, on the other. 
 
 The one comment, or perhaps I may without in- 
 justice say the one unfavourable criticism, that I have 
 heard passed, in Germany and elsewhere, about our 
 English system of education is that we place too much 
 stress upon, and indeed waste most precious and irre- 
 claimable time upon, the playing of games. In every 
 English school much is made of this playing of all 
 team games. In my day, and I hope it is so still, 
 more was thought by his school fellows of the athletic 
 achievements of a boy than of his intellectual prowess 
 in the schools. In the development of a boy's char- 
 acter, along the lines which in my country most 
 fathers wish their boys to go, the playing of games is 
 the most powerful and salutary influence. The games 
 are those in which a boy who is by nature an egoist 
 learns that it is the right thing to play for his side. 
 -He learns that it is not individual success that counts, 
 but victory for his team. Self is merged in the side 
 for which he plays. And by degrees he learns an- 
 other lesson more valuable still. It is that, though 
 quite rightly he may strive for victory, it is not only 
 victory that counts. He learns to play not for the 
 
THE CAUSES OF THE WAR 27 
 
 goal, but for the game. He finds that it is a nobler 
 thing to play cleanly than it is merely to win. And 
 he finds, too, not only in his youth, but through all 
 his life, that the finest epitaph that any man can earn 
 is this, "He played the game" — not, I beg you to 
 notice, "He won the game," or that he achieved this 
 or that most coveted honour or distinction, but just 
 simply that he "played" the game. Even in this war I 
 think we have an illustration of this very point. 
 Many new devices have come to the aid of all the 
 armies, and such science as each nation possesses has 
 been called in to aid the combatants. Is it not inter- 
 esting that all the dirty dodges, the gas attacks, the 
 liquid fire, the bombardment of open towns, the 
 metamorphosis of neutral embassies into bacterio- 
 logical laboratories, the unrestricted use of subma- 
 rines, have all come from one side.^^ And is it not in- 
 teresting that so many of the real and honest devices, 
 barrage fire, tanks, hand grenades, have come from 
 the other? It is satisfactory to know, however, that 
 when the Allies are compelled to retaliate, as they 
 did very tardily and regretfully, for example, in the 
 matter of gas attacks, the morbid ingenuity of the 
 German recoils upon himself very heavily. In these 
 matters, so far as we have had to make a rejoinder, 
 the Gertaian is now surpassed both by the French and 
 
28 __ AMERICAN ADDRESSES 
 
 ourselves. It would, as a piece of practical policy 
 have paid the enemy better to have "played the 
 game." The response may indeed be made that this 
 notion of playing the game for what the game is 
 worth is not enough; that victory and the fruits of 
 victory are really the ends in view. But we as sur- 
 geons know better. We are at work in our profession 
 for the sake of the task, not for the tribute that we 
 exact for our services. Our delight and our recom- 
 pense are in the good work we are able to do, not in 
 any paltry or imperfect pecuniary recognition of our 
 value. We practise that in a profession, not a trade, 
 and life is the most splendid and the most arduous 
 profession of all. The development of a man's charac- 
 ter, which allows the fullest expression of a man's life, 
 is, therefore, the motive and the mark of all methods 
 of liberal education. It is the "drawing out" of 
 something from the man himself (for that is what 
 education means) , as contrasted with the something 
 driven in, by the usages of the method of tyranny. It 
 is something added to the mere building up and shap- 
 ing of a man's mind. There is a charming legend 
 in one of the Apocryphal gospels. Some little children 
 were sitting by the wayside playing, and making mud 
 sparrows, when the Holy Child passed that way and 
 took the sparrows in his hands, warmed them in his 
 
THE CAUSES OF THE WAR 29 
 
 bosom, breathed upon them, and released them to 
 fly into the heavens. This should be the impulse of 
 liberty — an influence carrying life and freedom and 
 ecstasy with it. And what may we hope the quali- 
 ties of a whole nation to be whose individual members 
 are brought up in these ideals and by these methods.^ 
 Let us hope that they are justice in administration, 
 steadfastness, a spirit of tolerance, and moderation 
 in victory. 
 
 And in the practice of our profession am I in error 
 in thinking that I have noticed among those trained 
 in the ideals of liberty a gentler approach to the in- 
 dividual patient, a more anxious consideration for his 
 welfare, and a more tender sympathy and compas- 
 sion for his suffering than is found among that people 
 for whom technical skill counts more in public esteem 
 than do qualities of character .^^ 
 
 We have then in this war, as I believe, these con- 
 flicting and contending systems, tyranny and lib- 
 erty; autocracy and democracy; control and re- 
 pression from without, growth from within. And I 
 am deeply persuaded that an issue for the world of 
 science, almost as critical and as grave as any I have 
 mentioned, is at stake in our future. Tyranny long 
 exercised must mean a restriction of the intellectual 
 outlook, a fettering of our thoughts to customs and to 
 
30 AMERICAN ADDRESSES 
 
 ordinances that cramp our minds, an atrophy from 
 long disuse of that quality of mental effort which 
 makes for originality. Tyranny implies the negation 
 of scientific progress, though the unrestricted exercise 
 of its formulae may arrange in orderly precision all 
 the knowledge that others have acquired. Tyranny 
 means at last intellectual sterility and death. How 
 impossible it is for a nation held in the grip of tyranny 
 to give its citizens intellectual freedom, great though 
 its desire may be to do so ! Progress in science must, 
 first and last, depend upon the unrestrained freedom 
 of exercise of all the faculties of the human mind. 
 Of these, imagination is perhaps the chief. Imagina- 
 tion is the mother of fact. Or, one may say, it is the 
 scaffold upon which one stands to build the structure 
 of truth. Imagination, as Keats tells us, may be 
 compared to Adam's dream — he awoke and found 
 it truth. It cannot surely live fn the narrow restric- 
 tions and in the dank and stiflijig air where the 
 noxious weed of tyranny thrives. For, hamper it as 
 you will, thought in the long run must have its way, 
 which is the way of challenge and inquiry. Nor, I 
 think, can any work of enduring value come in the 
 absence of intellectual morality, the very existence 
 of which is threatened by that surrender of truth to 
 expediency of which I have spoken. And I believe 
 
THE CAUSES OF THE WAR 81 
 
 that the history of Germany in the last forty years 
 is the most convincing argument that can be brought 
 in favour of this thesis. In all this period she has dis- 
 played amazing industry, ungrudging toil; she has 
 organised and tabulated and made accessible to all 
 peoples the scientific work of every nation. She has, 
 indeed, been the intellectual clearing-house of the 
 world. It would be useless to belittle and impossible 
 to deny her intellectual value to the world. The best 
 of her is diligence. But her own original contribu- 
 tions to science are, I believe it to be beyond dispute, 
 the slenderest of any of the great nations of the world. 
 Tyranny is not a force to set ideas in motion. Under 
 a system of tyranny intellectual salvation can come 
 only from revolt. How else can we account for the 
 eternal freshness of the Jewish mind, and for the splen- 
 did achievements of that race which, tyrannized by 
 every power, has kept its own religion and lived its 
 own intellectual life, not by submission, but by re- 
 sistance to those who held its men in bondage? 
 Was not Pilgrim's Progress the cry of an unfettered 
 soul, and not of the body restrained by the bolts and 
 bars of Bedford Gaol.^ And was it not in Patmos 
 that St. John the Divine beheld the visions of the 
 Apocalypse? 
 
 In this war, as I see it, we are fighting therefore 
 
32 AMERICAN ADDRESSES 
 
 for liberty : of the two discordant systems of morals, 
 one only must triumph and survive. If we com- 
 promise with that which we believe to be a prin- 
 ciple of evil, a precursor of moral and intellectual 
 death and dissolution, we are false to those who have 
 given their most precious lives that truth might 
 conquer at the last, but more than this, we are false 
 to those who come after, we are robbing them of 
 their birthright, we are shackling for generations to 
 come the minds and the souls of men, we are failing 
 in our plain duty to humanity. 
 
GUNSHOT WOUNDS AND THEIR 
 TREATMENT 
 
 Surgeons who were responsible in the early weeks 
 of the present war for the treatment of the wounded 
 soldiers coming home from France are, I think, 
 never likely to forget their experience. There were 
 wounds of many dimensions and of every tissue, all 
 characterised by the most profuse and offensive sup- 
 puration. No one in active work had ever met with 
 cases like all of these. Whether a surgeon had prac- 
 tised "aseptic" or "antiseptic" surgery, he had been 
 able to secure with gratifying constancy a blameless 
 healing of the wounds he had made; he had rarely 
 seen a profoundly septic wound, and the methods he 
 had at his disposal for dealing with them were, al- 
 most always, easily capable of reducing and con- 
 trolling the infection. Suddenly he was confronted 
 with a long succession of cases in which a raging and 
 often a rancid suppuration was present, and he found 
 that all the old remedies, upon which he had so com- 
 fortably and so confidently relied, were hopelessly 
 inadequate and futile. A challenge was, so to say, 
 3 33 
 
34 - AMERICAN ADDRESSES 
 
 thrown to the profession, and I think we may now 
 with due modesty claim that it has been splendidly 
 and triumphantly met. Rebukes and taunts at our 
 incompetence were not seldom heard in those far- 
 off days. We were asked if Lister had worked in vain; 
 and we were told that we had failed to learn the lesson 
 he had spent his life in teaching. 
 
 It is interesting to read again the works of Lister, 
 and to see how helpless he felt himself in dealing 
 with putrefactive processes once firmly established 
 in a wound. Lister everywhere distinguishes be- 
 tween the "prophylactic" and the "therapeutic" 
 uses of antiseptics. All the marvellous achievements 
 of modern surgery are due to the adoption, by sur- 
 geons the whole world over, of the principle of the 
 prevention of infection in wounds about to be made, 
 as distinguished from that of the subduing of an in- 
 fection already rampant. 
 
 Lister writes: "The original idea of the antisep- 
 tic system was the exclusion of all microbes from 
 wounds." Again, "During the operation, to avoid 
 the introduction into the wound of material capable 
 of inducing septic changes in it, and secondly to 
 dress the wound in such manner as to prevent the 
 subsequent entrance of septic mischief." Again, 
 "In wounds already septic attempts are made with 
 
GUNSHOT WOUNDS AND THEIR TREATMENT 35 
 
 more or less success to restore the aseptic state." 
 Again, "In speaking of the antiseptic system of 
 treatment, I refer to the systematic employment of 
 some antiseptic substance so as entirely to prevent 
 the occurrence of putrefaction in the part concerned, 
 as distinguished from the mere use of such an agent 
 as a dressing." 
 
 The distinction between the preventive and the 
 curative use of antiseptics is in many respects that 
 existing, on the one hand, between the power of a 
 germicide as determined by experiments "in vitro," 
 and, on the other hand, its capacity to destroy 
 organisms when it is introduced among the living 
 and the dead tissues of a wound. In the former there 
 is a direct conflict, a clean fight, between the microbe 
 and the chemical agent. Few or none of the many 
 intervening conditions are present which have to be 
 considered when a bactericide is introduced into a 
 wound cavity wherein there are a multitude of ac- 
 tions and reactions which even now seem very ob- 
 scure and are so often conflicting. 
 
 When, after the lapse of many weeks from the 
 outbreak of war, there came a full appreciation of the 
 several circumstances which had to be reckoned 
 with when a soldier was wounded, it was recognised 
 on all hands that a new and grave problem had 
 
36 - AMERICAN ADDRESSES 
 
 arisen which cried urgently for solution. What, 
 then, were the several new factors that had to be 
 considered in this war? 
 
 In the early days a very large number of the 
 wounds were inflicted by rifle fire. The German 
 bullet has a muzzle velocity of approximately 1000 
 yards per second. In the first 800 yards or there- 
 abouts the flight of the bullet is not steady, but 
 ^'wobbling." There are three movements — a move- 
 ment forward along the line of flight; a rotatory 
 movement, in which the bullet spins round on its 
 longitudinal axis as a result of the "rifling" of the 
 barrel; and a third movement, a "mouvement de 
 bascule," of such a character that while the point 
 of the bullet keeps steady, the base of the bullet is 
 moving round a circle, or an ellipse, of a gradually 
 diminishing size. The result of the last form of 
 motion is this, that when the bullet impinges upon 
 any substance, even the soft clothing or the flesh, 
 the infinitely brief arrest of the point which strikes 
 first allows the base, which is, of course, much heavier, 
 to overtake the apex, and the bullet then lies side- 
 ways or begins to turn over and over as it ploughs its 
 way through the soft parts. In this early part of the 
 trajectory the missile has, of course, a great momen- 
 tum; it is a heavy bullet traveling with great veloc- 
 
GUNSHOT WOUNDS AND THEIR TREATMENT 37 
 
 ity. The consequence is that the damage inflicted 
 is not confined to the track it rudely makes through 
 the limb; the parts around the track are damaged 
 also, often to a great extent, and microbes are driven 
 deeply into all adjacent tissues. Every wound, 
 therefore, caused by a bullet at short range consists 
 not only in a visible tearing and destruction along 
 the path the bullet has followed, but in a dead zone 
 everywhere surrounding that track — a zone in which 
 death or destruction or disintegration of the parts 
 has occurred by reason of the tremendous concussion 
 produced by the bullet as it tore its way clumsily 
 through the tissues. Sir Anthony Bowlby has illus- 
 trated this by a series of exemplary instances. In 
 one of these the kidney was wounded in its lower pole; 
 the upper pole appeared normal to the naked eye, 
 yet on microscopic examination the tubules were 
 seen to be disorganised. Other examples of the wide- 
 spread damage inflicted are quoted in his Bradshaw 
 lecture. And even that is not all. The momentum 
 of the bullet is such that to everything it encounters 
 it imparts some of its own velocity. As we all know, 
 shreds of the clothing or belt, or the contents of the 
 pocket, may be carried deeply into a wound. So 
 also are pieces of skin or muscle. And if the bullet 
 should chance to strike a bone, the bone is not only 
 
38 AMERICAN ADDRESSES 
 
 broken into many fragments, — the "splinter" frac- 
 ture, — but to all fragments there is conveyed enough 
 of the momentum of the bullet to convert them into 
 projectiles also, capable of tearing a way into the 
 softer tissues. Many of the wounds, therefore, 
 were deep, irregular in shape, with large or small 
 cavities, of the variety the French term "anfractu- 
 ous." Into these recesses blood escapes, and, owing 
 to the tearing and unequal retraction of cut muscles, 
 pools of fluid may be shut off from the main track 
 of the wound and form an ideal breeding-ground 
 for all microorganisms, especially those which are 
 anaerobic. 
 
 If a rifle bullet is not checked in the first 600 yards 
 of its flight, it begins to steady down, and probably 
 when it has traveled 1000 yards it is moving evenly. 
 An injury inflicted then is of a quite different char- 
 acter. The bullet cleaves its way through the soft 
 parts, bores a neat hole through a bone, and little 
 destruction is done. We see many cases where the 
 chest or abdomen is traversed from side to side, or 
 where the neck has been pierced, and, miraculously, 
 no real damage has been done. Examples of this 
 form of injury were, of course, common enough in 
 the South African war. They have been less fre- 
 quent in this war because the range has often been 
 
GUNSHOT WOUNDS AND THEIR TREATMENT 39 
 
 shorter, and the bullet, in respect of velocity and 
 weight, is different. 
 
 During the last two years a very large proportion 
 of the wounds have been inflicted by shrapnel bul- 
 lets, hand grenades, or shell casing. The immense 
 velocity of the projectiles, especially when a high ex- 
 plosive shell bursts, their irregular shape, their pitted 
 surface and sharp edges all combine to cause wounds 
 of very diverse forms. The track is a distorted one, 
 the parts around it are bruised and battered or dead, 
 and the infection carried into the wound by a piece 
 of metal or cloth has unrestricted opportunities of 
 spreading rapidly. In many cases large areas of the 
 limbs or trunk are blown away; the wound remaining 
 shows a shattered and irregular surface; the muscles 
 are torn and crushed, or '* pulped," and lose their 
 structure. They dry rapidly on exposure, and there- 
 fore fall easy victims to a bacterial attack often of 
 great ferocity. 
 
 The condition of the battle-fields of Flanders and 
 of France accounts for the quality of the infective 
 agents. Many parts of the lands over which the 
 fighting has taken place, both before and since trench 
 warfare set in, were cultivated assiduously by the 
 rural inhabitants before the war. Probably no soil 
 in Europe has been more liberally manured in efforts 
 
40 ~ AMERICAN ADDRESSES 
 
 at intensive cultivation. Certainly no contact be- 
 tween the soldier and the soil has ever been more 
 intimate or more protracted. In the winter the whole 
 fighting zone is, in Sir Douglas Haig's phrase, a 
 "wilderness of mud." In the summer it rivals the 
 desert in a sand storm; dust is everywhere. It 
 steals into the eyes and nose and throat and ears, 
 it grimes the face and hands, it fills the hair, it pene- 
 trates every vestment. Every projectile passing 
 through the garments to the body will certainly be 
 covered with the mud or dust in the clothes, and with 
 the many organisms that respite from ablutions has 
 allowed to penetrate the skin. All bacteriologists and 
 surgeons are now agreed that no influence perpetuat- 
 ing infection in a wound is so malign as that which 
 is harboured in the torn fragments of clothing. The 
 physical condition of the soldier himself, when he is 
 wounded, no doubt plays an important part in exalt- 
 ing the virulence of any infection which may settle 
 upon him. Though in the best of health and physical 
 condition at the moment of attack, he may, by the 
 time he is wounded, have suffered great fatigue, and 
 bleak exposure, for hours, or even days, before suc- 
 cour comes to him. The organisation for the collec- 
 tion and despatch to the field ambulances and Cas- 
 ualty Clearing Stations of wounded men is probably 
 
GUNSHOT WOUNDS AND THEIR TREATMENT 41 
 
 as perfect as any endeavour can make it. But there 
 are times, especially in a "push," when a man may 
 lie out undiscovered for long periods. Not infre- 
 quently by reason of such causes, and on account of 
 pain and hunger and loss of blood, he may be reduced 
 to a state in which his power of resistance to a bac- 
 terial attack is greatly impoverished. 
 
 BACTERIOLOGY 
 The bacteria infesting the wounds in France have 
 been studied by Wright, Fleming, and others. The 
 general conclusion drawn from their work is that the 
 microorganisms, as might be expected, are those found 
 in highly manured soil; they are, that is to say, of 
 fecal origin. Wright suggests, with his customary 
 fecundity of invention, the new names "serophytes" 
 for those organisms which will grow in normal serum, 
 streptococci, and staphylococci, and "serosapro- 
 phytes" for those which can grow only in digested 
 albumens. The native albumens of human serum are 
 "protected" from bacterial development at their ex- 
 pense, and Wright points out that, if this were not so, 
 human life would have been impossible. Among the 
 serosaprophytes are the larger number of the organ- 
 isms found in wounds, including all the anaerobes; 
 the bacillus of Welch, the bacillus of tetanus, the 
 
42 AMERICAN ADDRESSES 
 
 enterococcus, a streptococcus of intestinal origin de- 
 scribed by the French, the bacillus coli, and putre- 
 factive bacilli X and Y, which are the cause of the 
 foul odour often met with in wounds. There is often 
 a '*wisp" bacillus, and a diphtheroid bacillus appears 
 in later stages of the infection. 
 
 All these microorganisms find a most fertile medium 
 for their growth in wounds of the character I have 
 described. In every anfractuous wound, where the 
 recesses are many and intricate, blood or serum may 
 be poured out; tryptic digestion begins as a conse- 
 quence of the destruction of the leukocytes, peptones 
 are formed, and bacteria, finding everything to their 
 liking, grow apace. From many of the wound sur- 
 faces the circulation has been cut off by the powerful 
 stunning effect of the blow given by the projectile, 
 and gangrene and sloughing make haste to develop. 
 During the first four to six, or in some cases even 
 eight, hours few organisms or none can be recovered 
 from the wounds, either by smear methods or by 
 cultural methods. The organisms are there, never- 
 theless, and, given the prodigal fertility of the soil 
 in which they are sown, will quickly show the evidence 
 of their growth. In this brief early period the wound 
 is said to be "contaminated"; in all later periods, 
 "infected." Against this attack made upon it by 
 
GUNSHOT WOUNDS AND THEIR TREATMENT 43 
 
 immeasurable millions of organisms, how does the 
 body protect itself? The chief defence is in the blood- 
 serum and in the leukocytes (phagocytes). The 
 capacity of these two, if only they have an adequate 
 chance, may be said to be almost illimitable against 
 all organisms but the streptococcus. The serum 
 possesses strong bactericidal powers of its own; the 
 phagocytes can devour bacteria greedily. But in 
 exerting their powers both serum and white cells are 
 apt to undergo degradation. The leukocyte breaks 
 down and its power of tryptic digestion is then exerted 
 upon the fluids around it, and peptones are produced 
 in quantities which make easy the growth in them of 
 all forms of bacteria. Moreover, the surface of the 
 wound soon becomes "lymph-bound." A mesh of 
 fibrin entangles the blood-cells, and a sort of matting 
 of coagulated lymph spreads over all the surface. 
 No fresh serum can then reach the wound, nor are 
 fresh leukocytes available for the attack. The infec- 
 tive process can then proceed apace, unhindered by 
 those powerful natural defences which for the moment 
 have quite broken down. 
 
44 AMERICAN ADDRESSES 
 
 THE PRINCIPLES AND METHODS OF TREATMENT 
 OF GUNSHOT WOUNDS 
 
 (a) Primary Closure 
 Every one to whose lot it has fallen to undertake 
 the surgical treatment of wounds in this war will agree 
 that the most urgent need is to secure their complete 
 closure at the earliest possible moment. In the early 
 hours, during the period of "contamination," it is 
 now the common practice to excise freely all damaged 
 and dead tissue if possible in one piece. This requires 
 some skill and no little practice to do excellently. 
 The most careful preparation of the skin and the 
 parts around the wound is a necessary antecedent to 
 any operative measures. The wound, of whatever 
 type, is excised, together with a wall not less than 
 3^^ inch around it. In order to make certain that all 
 the walls of the original wound are excised, Wilson 
 Hey has suggested and has long employed a method 
 of staining with brilliant green, which is injected into 
 all parts of the wound, and allowed to remain not 
 less than two minutes. The staining of a wound not 
 only makes a more thorough removal possible, but 
 it also indicates those parts which cannot or may not 
 be removed, to which, therefore, a simple mechanical 
 cleansing must be more particularly directed. When 
 
GUNSHOT WOUNDS AND THEIR TREATMENT 45 
 
 staining has been thought unnecessary, he tells us the 
 final results are worse. Staining in every case is a 
 help : it is never a hindrance. The walls of the cavity 
 remaining after excision should bleed everywhere — 
 perfect hsemostasis is then secured. Every soiled in- 
 strument or glove is at once discarded. The wound 
 may then be stitched up completely without drain- 
 age, and with much confidence may be expected to 
 heal well. The cases coming to the base hospitals in 
 England show that in a great variety of injuries this 
 method of the primary closure of wounds is meeting 
 with a very remarkable success. If the operation is 
 carried out with scrupulous exactitude and with 
 something near to technical perfection in cases of 
 the smaller "contaminated" wounds, where there 
 is no loss of substance, probably not less than 80 
 per cent, will heal by first intention. The failure 
 occurs in those cases where a piecemeal removal of 
 the infected wall has been carried out, where, that is 
 to say, there has been a frequent reinfection of the 
 newly made raw surfaces. 
 
 There has been in all armies a certain timidity, 
 very natural, and perhaps from many points of view 
 very desirable, in carrying out the method of primary 
 closure. No one who has worked, even for a brief 
 period, in the armies in France can have failed to 
 
46 AMERICAN ADDRESSES 
 
 realize the desperately serious results which come 
 from the injudicious closure of septic wounds. Gas 
 gangrene, for example, may develop in an ampu- 
 tated stump if even one stitch is put in to approxi- 
 mate the flaps. And there has consequently sprung 
 up on all sides a fear of the premature closure of 
 wounds. But recent experience would seem to show 
 that, at least in the early cases, in cases reaching a 
 well-equipped surgical unit, say within eight or ten 
 hours, in the period of contamination rather than of 
 spreading infection, a mechanical cleansing of the 
 most thoroughgoing kind, carried out ruthlessly and 
 rapidly, will allow the majority of the cases to be 
 closed with an excellent chance of primary union. 
 There can no longer be any doubt that many of the 
 cases which have proved so successful under the 
 Carrel-Dakin method, applied during the first six 
 to eight hours, would have closed equally safely, 
 and far more rapidly, under the method of immediate 
 suture; and that consequently a certain degree of 
 suffering and much expenditure of time and no little 
 expense would have been saved. To put this state- 
 ment in what may seem an extreme fashion it may be 
 said that the Carrel-Dakin method has achieved its 
 greatest triumphs in cases where it need not in fact 
 have been applied. But if this opinion is true, it 
 
GUNSHOT WOUNDS AND THEIR TREATMENT 47 
 
 must at once be admitted that one of the chief ex- 
 periences which have led to its realization is the 
 practice of this method, with great success, during 
 many months, More than ever are we now con- 
 firmed in our strong opinion that it is the primary 
 mechanical cleansing, after thorough exposure, and 
 with every precaution and care, that is the supreme 
 necessity in all cases; and that this alone, if complete, 
 will often allow the natural defences of the body to 
 secure the blameless healing of the wound. 
 
 (6) Secondary Closure 
 If, however, owing to one or more among a great 
 diversity of circumstances, the patient arrives at a 
 base hospital with a freely suppurating wound, the 
 problem is quite different. The chance of primary 
 closure has passed away perhaps long ago; the wound 
 now may be covered, sparsely or thickly, with sloughs 
 of varying size and in various stages of detachment. 
 Layers of lymph adhere at one point, or at many, to 
 the wound surfaces, and the discharges are thick, 
 purulent, and offensive. The problem here is first 
 to secure a healthy and relatively uninfected surface, 
 and secondly to close the wound by suture on the 
 earliest prudent occasion. What are the principles 
 which we must now put into practice .^^ For purposes 
 
48 AMERICAN ADDRESSES 
 
 of tabulation and description they may be spoken 
 of as "physiological" and "antiseptic," though, as I 
 shall presently indicate, the difference between the 
 two may not be so sharp as such a precise and limited 
 statement might appear to indicate. 
 
 I. Physiological Methods. — ^These owe their origin 
 to Sir Almroth Wright. The problem Wright set 
 himself to solve, in the case of the septic "lymph- 
 bound" wound, was that of rendering available, 
 once more, all the natural defensive mechanisms 
 possessed by the body fluids and tissues, and of 
 exalting their power by bringing them into play in 
 far larger quantities than are usually at our com- 
 mand, and in a condition which, as a result of vaccine 
 injections, or because of the increased antitryptic 
 power of blood-serum of a wounded man, finds them 
 greatly augmented. We have, he says, to promote 
 the destruction of the microbes which have been 
 carried into the deeper tissues; we have to resolve 
 the infiltration in the walls of the wound, and to get 
 rid of infected sloughs; we have to prevent the "cor- 
 ruption of the discharges," and to inhibit microbic 
 growth in the wound; we have to be constantly on 
 our guard in order to prevent those active and passive 
 movements which propel bacteria along the lym- 
 phatics, and which carry poisonous bacterial prod- 
 
GUNSHOT WOUNDS AND THEIR TREATMENT 49 
 
 ucts into the blood; and finally, all this being done, 
 we have to get rid of the surface infection, promote 
 the processes of repair in the wound, and bring to- 
 gether the wound surfaces so that they may heal. 
 How are these various tasks successfully accom- 
 plished? 
 
 The blood serum, as Wright has shown, possesses 
 certain remarkable properties. Mechanically it is 
 the agent by which phagocytes are washed on a ris- 
 ing tide into the wound, and chemically it has a power- 
 ful bactericidal efficiency against all microorganisms 
 but the "serophytes," streptococci, and staphylo- 
 cocci; the anaerobic organisms, that is to say, are 
 destroyed by it. The phagocytes, as Metchnikoff 
 long ago showed us, can devour and digest micro- 
 organisms of all kinds, but, tried beyond a certain 
 point, they perish in the fight, and liberate at their 
 death a ferment, trypsin, which digests the native 
 albumens in the serum, converts them into peptone, 
 and therefore adds enormously to the cultural value 
 of the wound discharges. The blood, however, is 
 normally antitryptic, and this quality appears in 
 cases of infection to be increased; there is an anti- 
 dote, that is to say, to the local defeat of the phago- 
 cytes and the consequences attaching thereto. The 
 coagulability of the serum is also increased, with the 
 
 4 
 
50 AMERICAN ADDRESSES 
 
 result that a "felting" of fibrin forms on the walls of 
 the wounds and prevents the access to the wound 
 of reinforcements of serum and of cells. Wright's 
 method consists in the application of a "hypertonic" 
 solution of salt, 5 per cent, or anything over that, 
 together with 3^ per cent, citrate of soda (this is not 
 necessary). The principle of the hypertonic method 
 is to make use of the bactericidal power of fresh 
 serum, which is encouraged to flow from the wound 
 surfaces by the application to them of a more con- 
 centrated saline solution than blood-serum. A proc- 
 ess of osmosis is at work. It is argued, or rather 
 asserted, which is not the same thing, that serum is a 
 fluid which will not osmose, but the fact is indis- 
 putable that when these strongly saline dressings 
 are applied, the discharge from all the wound sur- 
 faces is increased enormously in quantity. The 
 patient is often compelled to drink freely, so con- 
 siderable may the drain of the fluid be. The discharge 
 from the wound after the first few hours becomes clear 
 and within three or four days may be found sterile 
 or of low bacterial content. The streptococcus is by 
 far the most resistant of all microorganisms; after 
 three to five or six days it is often the only germ re- 
 maining. As I go around from one hospital to another, 
 or from one ward to another, I think I am generally 
 
GUNSHOT WOUNDS AND THEIR TREATMENT 51 
 
 able to pick out the cases which are being dressed by 
 Wright's solution. The granulation tissues have a 
 fuller, deeper colour, and the surface looks cleaner 
 than when any other form of dressing is being used. 
 
 The blood-serum has now done its work. During 
 this time the phagocytes have been inhibited in 
 their action and even destroyed, as I shall presently 
 mention. It is their aid which is, however, supremely 
 necessary in the attack upon the serophytes. The 
 hypertonic solution is therefore changed for an 
 isotonic solution, which encourages the migration of 
 leukocytes and leaves them to deal with the strepto- 
 cocci and staphylococci (generally few in number) 
 that alone remain in the wound. When bacteriolog- 
 ical examinations reveal that the wound is "clinically 
 sterile," it may be closed by suture or its edges ap- 
 proximated by strapping. 
 
 The action of hypertonic saline solutions is com- 
 plex, and its virtues are conflicting. It attracts water 
 from the blood, together with all the protein sub- 
 stances contained therein; it inhibits leukocytic 
 migration, prevents phagocytosis, disintegrates those 
 leukocytes with which it is brought into direct con- 
 tact, and thus sets free a tryptic ferment which di- 
 gests the albumens of the blood-serum. It delays 
 or prevents the action of this very ferment which it 
 
52 AMERICAN ADDRESSES 
 
 has caused to be liberated. It inhibits coagulation 
 and so prevents the sealing up of the channels through 
 which lymph pours into the wound. It appears de- 
 finitely to inliibit bacterial activity and propagation. 
 Various modifications of Wright's original proce- 
 dures have been made. Before I left France for the 
 first time in March, 1915, we had begun to use salt 
 tablets, wrapped in gauze, in the wound, at the sug- 
 gestion of Colonel Lawson, with the intention of 
 keeping available in the wound cavity a constant 
 supply of hypertonic solution. This method was 
 afterward widely used and warmly advocated by 
 Colonel Gray and Major Hull, who designed the 
 "salt pack," a most useful and valuable form of 
 dressing. After appropriate cleansing a wound may 
 be filled with a number of salt packs, protected by a 
 few layers of gauze from actual contact with the 
 granulating surfaces, so as to avoid sloughing, and 
 left for eight or ten days. The dressing becomes very 
 offensive; but on its removal a bright, even, and 
 healthy layer of granulations covers every part of 
 the wound. This method is of great value in many 
 cases of secondary haemorrhage where only smaller 
 vessels are involved ; and in those cases where trans- 
 ference of the patient from one hospital to another is 
 necessary. Colonel Sargent has recently used an 
 
GUNSHOT WOUNDS AND THEIR TREATMENT 53 
 
 ointment made of vaselin with 5 per cent, salt added 
 thereto; after a thorough cleansing and a sparing 
 application of this preparation, a secondary closure 
 of the wound will be followed by healing. The 
 various papers of Sir A. Wright on "physiological 
 methods" and on the treatment of wounds have 
 helped us to realize better than ever before the 
 immense complexity of the problems concerned with 
 the healing of septic wounds and clearly to under- 
 stand the principles upon which we must rely in 
 order to promote union. 
 
 Antiseptic Methods. — Before any discussion with 
 regard to antiseptic methods can be productive of 
 good we must ask ourselves the question, "What is 
 it we expect an antiseptic to do in an infected wound? " 
 The answer most commonly given by those to whom 
 I put this question is that an antiseptic acts by de- 
 stroying bacterial life. But a great many qualifica- 
 tions must be given before such a reply can receive 
 even a slender acquiescence. The problem of the 
 action of an antiseptic in an infected wound is far 
 too complex for a simple and ready answer. We know 
 in truth very little even now of what goes on in all 
 parts of a septic wound. But we may be quite cer- 
 tain that an antiseptic is never "monotropic," en- 
 gaging one substance only. It may have an affinity 
 
54 AMERICAN ADDRESSES 
 
 for the tissues forming the wall of the wound, for the 
 serum, or for the leukocytes; or for any "corrupt- 
 ing" discharges which remain in the wound; or for 
 the gauze packed into the cavity of the wound ; or for 
 the dressings applied to the surface. It may have op- 
 posing effect on different parts of the wound; it may, 
 for example, increase proteolytic digestion in its ac- 
 tion upon sloughs, and it may inhibit or prevent this 
 process by its effect upon leukocytes and their emigra- 
 tion. An antiseptic, however potent in vitro, may 
 be quenched by the other substances I have named 
 and fail to influence the bacteria in any direct way. 
 Moreover, the bactericidal power of an antiseptic is 
 no criterion of its penetrative power. Its bactericidal 
 power is at once profoundly modified by its contact 
 with albumen, with which it most eagerly combines, 
 as is also its power of diffusion, and therefore of reach- 
 ing in a still active condition all the crannies and 
 chinks among the recesses of the wound. The direct 
 germicidal effect of any antiseptic is, therefore, 
 almost certainly, very much smaller than many of us 
 had supposed, and is confined chiefly or exclusively 
 to those bacteria which are lying bare to its attack 
 in the open wound. I have, moreover, always thought 
 it very difficult to credit the supposition that an 
 antiseptic, however applied, can have an efficient 
 
GUNSHOT WOUNDS AND THEIR TREATMENT 55 
 
 action against microorganisms in a wound without 
 producing also a very harmful effect upon the body 
 tissues and fluids. Or, in other words, exclusive re- 
 liance upon an antiseptic to act as a germicide is a 
 negation of all dependence upon the principles of 
 physiological reaction of the tissues to a bacterial 
 attack. These points will emerge more clearly in 
 connection with a brief description of the various 
 methods of "antiseptic treatment" adopted at the 
 present time in the zones of the war. 
 
 Among them pride of place will cheerfully and 
 gratefully be conceded to the ^' Carrel-Dakin'* pro- 
 cedure. It consists, as all surgeons now know, of 
 a free mechanical exposure and cleansing of the whole 
 wound. This is so easy to say and, alas! so diflScult 
 in all cases to carry out adequately. The wound so 
 made is then lightly packed with gauze into which 
 a number of Carrel's tubes are laid; through these 
 tubes at intervals of about two hours Dakin's fluid 
 is instilled. Probably full realisation of the need for 
 careful preparation and testing of Dakin's fluid is 
 not universal; nor of the rapid deterioration in its 
 potency if it is allowed to be heated, or exposed to 
 the air, or stored in transparent glass bottles in warm 
 places. The method allows of the early secondary 
 closure of wounds, at an average period of eight to 
 
56 AMERICAN ADDRESSES 
 
 twelve days; and coming when it did before the end 
 of the first year of the war it is no exaggeration to 
 describe its effects upon the treatment of wounds as 
 revohitionary. 
 
 In what way does the Carrel-Dakin method act? 
 Are its effects produced by reason of the strongly 
 antiseptic properties of Dakin's fluid, or because of 
 other properties not directly concerned with the kill- 
 ing of microorganisms? Or is the most excellent tech- 
 nique for which we cannot be too grateful to Carrel 
 chiefly responsible in that it necessitates a greater 
 general care of the wound, a free opening of all re- 
 cesses, and that constant supervision which detects 
 at the earliest moment any harmful development on 
 the granulating surface? If strict dependence is 
 placed upon the microbial curve, it would appear 
 that the author of the method believes that pro- 
 gressive sterilisation of the wound is produced by the 
 chemical action of Dakin's fluid upon the bacterial 
 flora. The reduction in the number of organisms, 
 even irrespective of their nature, is held to be the 
 index of the germicidal effect of the fluid applied. 
 Even when comparatively small quantities of a 
 potent bactericidal fluid, like that discovered by 
 Dakin, are instilled frequently into wound cavities 
 covered by sloughs or granulations, the killing of 
 
GUNSHOT WOUNDS AND THEIR TREATMENT 57 
 
 microbes may not be of serious consequence. For 
 these organisms can propagate themselves at a rate 
 with which the most powerful germicide could hardly 
 "catch up" however frequently or adequately sup- 
 plied. I can easily conceive of an "antiseptic," using 
 the word in its clinical sense, which is not in the 
 smallest degree "germicidal." I can understand, 
 that is to say, that a wound, however gravely in- 
 fected, may, by the application of some chemical sub- 
 stance, be deprived of its bacterial flora, in very 
 great measure, or even completely, though no single 
 microorganism is killed by this substance. An 
 "antiseptic," if not germicidal (that is, not acting 
 chemically upon the substance of which bacteria are 
 composed) , might yet render the wound sterile either 
 by destroying the pabulum of the bacteria, so that 
 they were unable to flourish and to propagate, or 
 by exalting those normal powers of resistance pos- 
 sessed by body tissues and fluids, or by holding up 
 the bacteria until those powers, without increase, 
 are capable of destroying or dispelling the infective 
 agents. Or does the action of chemical agents on the 
 leukocytes so alter their metabolism as to produce 
 substances which cause degenerative processes in the 
 bacteria? That is, are involution forms of bacteria 
 developed by the relationship of these agents to 
 
58 AMERICAN ADDRESSES 
 
 them? The most striking effect visible to the eye in 
 a wound treated with Dakin's solution is that the 
 surfaces are cleaned very rapidly. Dead tissue, 
 even large sloughs, are quickly digested away, and 
 the surface becomes smooth, clean, and bright red 
 in colour. In a wound not yet clean in all its parts 
 a very different microbial curve can be drawn if 
 smears are taken from the smooth red portion of the 
 surface and from the edge of a slough. It is the dead 
 tissue in the wound that keeps the septic processes 
 going. If this is destroyed, bacterial profusion and 
 virulence both rapidly diminish until the wound is 
 "clinically sterile." If, therefore, a substance could 
 be found which, without having a directly noxious 
 effect upon bacteria, could rid the wound of all dead 
 tissue and allow the natural defensive mechanism 
 to have a free chance, it is possible that the wounds 
 would heal as kindly as they do under the Carrel- 
 Dakin system. 
 
 What appears to be a fulfilment of this supposition 
 has been published since the foregoing paragraph was 
 written. Donaldson and Joyce* describe a non- 
 pathogenic spore-bearing anaerobe which acts, ap- 
 parently in virtue of its proteolytic powers, only on 
 devitalized tissues, and possibly on toxalbumins, 
 * Lancet, 1917, ii, 445. 
 
GUNSHOT WOUNDS AND THEIR TREATMENT 59 
 
 and appears to possess no power of attacking healthy 
 tissues. The powers of this organism are directed 
 not only toward the removal of the grossly damaged 
 tissues, but it succeeds also in attacking the micro- 
 scopically damaged structures. As a result the body 
 forces are freed from the constant menace of septic 
 poisoning and are thus allowed to commence the 
 work of repair. It is therefore an arguable proposi- 
 tion that Dakin's fluid as applied by the Carrel 
 technic does not act only as a germicide, but also, 
 perhaps chiefly, as a proteolytic agent, as an agent 
 destroying those parts of the wound on which alone, 
 or chiefly, organisms can find a place to propagate. 
 It is, after all, therefore, the mechanical cleansing of 
 the wound which is of the greatest importance, and 
 the action of Dakin's fluid is perhaps very much the 
 same as that of the surgeon's knife in these cases 
 where the wound is excised. 
 
 The Carrel-Dakin method always stops short of 
 perfection in asepsis. In my experience the wound 
 is never rendered "sterile" by this method. Organ- 
 isms can be found in smears and developed in culture, 
 however long the treatment is continued in a large 
 wound, a fact which seems to me of great significance 
 in relation to the question of the bactericidal value 
 of Dakin's fluid. For when fluid in the same quantity 
 
60 AMERICAN ADDRESSES 
 
 as ever is applied, and but few microorganisms re- 
 main, their ultimate annihilation appears to be im- 
 possible. Perfect sterility, however, we have long 
 known is not necessary for a healing by first intention; 
 though the quality of that healing varies decidedly 
 according to the relative infectivity of the wound. 
 The fewer and less harmful the organisms, the more 
 blameless is the healing. Surgeons who have worked, 
 as surgeons should work, with a bacteriologist at 
 their elbows, will admit they have constantly closed 
 wounds which were proved to contain microorgan- 
 isms, and yet have obtained a union of the wound that 
 was good. Until I adopted my present technique this 
 was a frequent experience; but many years ago I 
 began (I was, I believe, the first to begin) the cover- 
 ing of the skin by tetra cloths which overlapped the 
 skin edges, and since then I can be certain that in 
 all clean cases the wound remains sterile to the end 
 of the operation and a flawless healing can be con- 
 fidently expected. Carrel has coined the phrase 
 "clinical sterilisation" to indicate that condition 
 in which organisms are so few that the wound can 
 safely be closed and good healing obtained. Regard 
 should, however, be paid not only to the number of 
 the microbes, but to their nature. I do not like to 
 find a streptococcus present when the day approaches 
 
GUNSHOT WOUNDS AND THEIR TREATMENT 61 
 
 for the secondary suture of a wound. Carrel's method 
 must rely at the last upon the living properties of the 
 tissues to destroy or render innocuous the organisms 
 still remaining in the wound when it is closed. It 
 is true that they are few: but they are there, never- 
 theless, and must be overcome if the wound is to heal 
 and to remain healed. What most surgeons have 
 learned since the introduction of this technique is 
 that which those surgeons who worked in association 
 with a bacteriologist have long known, namely, that 
 infected wounds (wounds "clinically sterile") may 
 heal in a manner to which the term *' first intention" 
 may without injustice be applied. 
 
 What are the disadvantages of the Carrel-Dakin 
 method? I often hear it said that it is a difficult 
 method, requiring a special training of the surgeon, 
 that it requires a large amount of glass and rubber 
 tubing, bottles, etc., that it is costly in dressings, 
 and that it calls for constant supervision or direction 
 by the surgeon. There is truthfully no great validity 
 in these objections. A special instruction of the sur- 
 geon is certainly necessary if he is to observe the 
 ritual carefully, and to understand what it means; 
 but so it may be said is a special training necessary 
 for the surgeon when any new technical procedure is 
 introduced. The apparatus is cheap, and is easily 
 
62 AMERICAN ADDRESSES 
 
 obtained and lasts with care for months. If nurses 
 are carefully trained to do the dressings with punctil- 
 ious care, only that supervision is needed from the 
 surgeon which he should give to every case. From a 
 military point of view, however, it is a difficult method 
 to practise on a large scale, for in our army we are 
 compelled to evacuate a large proportion of our cases 
 to England, retaining in advanced positions, or even 
 at the base in France, only those classes of cases for 
 which movement has proved disastrous. The circum- 
 stances under which Carrel worked and under which 
 he obtained his splendid results could not conceivably 
 be made applicable to a whole army. Some part of his 
 success must truthfully be attributed to his oppor- 
 tunities for receiving cases early and for retaining 
 them for long periods. 
 
 The chief disadvantage of the method is that if it 
 is interrupted, it fails lamentably. When cases have 
 to be transferred from France to England, it may for 
 certain reasons be impossible to survey all the cases 
 on board ship or on the train; and infection then 
 spreads, and a reeking and rampant suppuration is 
 present when the patient arrives at a base hospital 
 in England. This is, it is true, an objection to a par- 
 ticular application of the method, rather than to the 
 method itself. But it is the reason, I think, that the 
 
GUNSHOT WOUNDS AND THEIR TREATMENT 63 
 
 procedure has never found a wide or general accep- 
 tance in the British army, though it has many warm 
 advocates, and many who practise it with a success 
 equal even to that of Carrel or of Chutro. The chief 
 successes obtained by this method are in the early 
 cases, in those in which treatment can begin not 
 more than six or seven hours after the wound is made. 
 But we are by degrees becoming less timorous in our 
 efforts at primary closure in precisely this group and 
 our results justify a wider acceptance and a more 
 general adoption of this practice. In later cases the 
 Carrel method is beyond question a therapeutic pro- 
 cedure of the first magnitude, but it then requires 
 unwearying care and inexhaustible patience and a 
 variety of favouring circumstances if the best results 
 are to be attained. 
 
 In times of leisure the method is good; in times 
 of war, with all the haste of war, it will often fail. 
 "C^est magnifique, mais ce n'est pas la guerre.'^ 
 
 Rutherford Morison's Method. — ^This method is 
 widely practised in the base hospitals in England, and 
 by many surgeons is considered the most satisfactory 
 of all. The technique is as follows: A wound, say of 
 the arm, leading down to a compound comminuted 
 fracture of the humerus, is freely opened up, after such 
 preparation of the arm and of the surrounding parts 
 
64 AMERICAN ADDRESSES 
 
 as is made in all cases about to undergo operation. 
 The skin, that is to say, is prepared with soap, anti- 
 septic washes (Morison uses 1 : 20 carbolic acid lo- 
 tion), and spirit. The wound may be enlarged in any 
 direction in order to make sure that no recesses in it 
 remain undiscovered. All granulation tissue is vig- 
 ourously scraped away from the wound surfaces; 
 bleeding points are secured; obviously dead and loose 
 portions of bone, or pieces of cloth or projectiles, are 
 removed. The wound is packed with dry gauze for 
 a minute or two, while towels about the wound are 
 changed if necessary, and while the surgeon replaces 
 all instruments, gloves, etc., with those freshly steril- 
 ized. The dry gauze is removed, the wound sponged 
 everywhere with gauze moistened with methylated 
 spirit. Onto the raw wound surface a thin layer of a 
 preparation known as "Bipp" (bismuth subnitrate or 
 carbonate one part, iodoform 2 parts, paraffin in 
 quantity sufficient to make a soft paste). With a 
 gauze swab this paste is rubbed well into the wound, 
 which is then sutured from end to end without drain- 
 age. The arm is fixed on a splint and the wound left 
 untouched for ten days. At the end of this period it 
 is usually found healed or nearly so ; another dressing 
 is applied, and allowed to remain ten days. No fur- 
 ther dressing is needed. The absence of frequent 
 
GUNSHOT WOUNDS AND THEIR TREATMENT 65 
 
 dressings is an immense advantage and a comfort 
 beyond words to an anxious, overwrought patient. 
 
 Why does Morison's method prove so successful? 
 Is it the free mechanical cleansing of the wound that 
 is of chief importance, or is there some antiseptic or 
 physiological virtue in the "Bipp" as a whole, or in 
 any of its constituent parts? It is almost certain that 
 in the perfect mechanical cleansing of the wound lies 
 the secret of the method. For I have treated wounds 
 in exactly Morison's manner and have omitted the 
 paste, and have seen the wounds heal as kindly as 
 when it was used. If there is a virtue in the paste, 
 in which of the ingredients does it lie? Probably in 
 the paraffin which produces that anaerobic state in 
 which healing can most rapidly take place. Mr. 
 Morison, at my suggestion, tried his methods in two 
 cases, omitting the "Bipp," and he allows me to say 
 that they healed as well as the others treated with 
 the paste. What disadvantages attach to the "Bipp" 
 method? There have been several cases of bismuth 
 poisoning, and I have seen one of iodoform poisoning. 
 In a certain number of the wounds, especially those 
 which have been treated in France, the paste has been 
 discharged in driblets, or in lumps, after the whole 
 wound has broken down. These faults are due to a 
 wrongful application of the method. Perhaps less 
 
66 AMERICAN ADDRESSES 
 
 than the necessary care has been given to the thor- 
 ough opening of the wound, and certainly far too 
 much of the paste has been introduced. One writer 
 says, "The wound must be filled with 'Bipp'"; that 
 instruction is, of course, the very opposite of the 
 truth. If the paste is used at all, only the thinnest 
 smear is applied to the wound surfaces. The excel- 
 lent and indubitable results of Morison's method 
 have started once again the quest of the healing balm. 
 All sorts of composite unguents and embalming ma- 
 terials have been tried with the hope of obtaining a 
 substance having an action that may be described as 
 a sustained push compared with the "thump" given 
 by Dakin's fluid. A very practised surgeon. Captain 
 Wilson Hey, has used with excellent effect a paste 
 of which boric acid, paraffin, chalk, and brilliant green 
 are the ingredients, and equally good results follow the 
 use of pastes or powders containing chloramin-T and 
 acriflavine. Many control experiments by different 
 observers using the several pastes, or none, are still 
 necessary before we can say if any of them, or any 
 parts of them, are essential to an equal degree of sound 
 healing in the wounds. Recently what may prove 
 to be the most valuable antiseptic yet tried has been 
 used in groups of cases under the care of a few ob- 
 servers. This is dichloramin T, introduced by Dr. 
 Dakin. 
 
GUNSHOT WOUNDS AND THEIR TREATMENT 67 
 
 Flavine Compounds. — During the last few months 
 great interest has been aroused in the surgical world 
 by the writings of Browning and other workers in 
 the Bland-Sutton Institute of Pathology in praise 
 of flavine as an antiseptic for application to infected 
 wounds. Browning claims that flavine compounds 
 (proflavine, acriflavine) and brilliant green exert a 
 slowly progressive bactericidal action; in concen- 
 trations which inhibit and finally kill bacteria no 
 harmful effect upon the tissues or upon phagocytosis 
 is produced. It is said of the flavine compounds that 
 their bactericidal potency is enhanced by the pres- 
 ence of serum; brilliant green, on the other hand, 
 is reduced in activity by serum. The experiments of 
 Browning are criticised by Fleming and Tanner and 
 others. Fleming asserts that when many microbes 
 are used in similar experiments to those of Browning 
 the flavine must be in far greater strength than that 
 given as the *' lethal concentration," in order to effect 
 sterilisation; that in a concentration of 1:2000 
 flavine completely inhibits leukocytic emigration; that 
 it has, if tested over a period of twenty-four hours, 
 a greater destructive effect on leukocytes than on 
 bacteria. Carrel has also spoken of the weak anti- 
 septic action of flavine, of its inefficiency under the 
 conditions which really obtain in wounds, of the 
 
68 AMERICAN ADDRESSES 
 
 destructive effect upon the granulations of a wound, 
 producing necrosis, arresting cicatrisation, and in- 
 creasing the dimensions of the wound if used for any 
 length of time. We have had in Leeds, under the 
 direction of Major Braithwaite and Lieutenant 
 Gruner, an experience of the flavine compounds ex- 
 tending over many weeks and embracing a great 
 variety of cases, and a trial of different methods of 
 application has been made (Carrel technique, twelve- 
 hourly dressings, etc.). The naked-eye changes are: 
 An early reddening of the surface, a considerable 
 diminution of the exudate, a disappearance of the 
 fibrinous deposit, a firmer consistence of the granu- 
 lations. If long continued, the flavine produces a 
 more brilliant red tinge in the wound, a *' beefy" 
 look, and apparently all processes of healing are held 
 in complete abeyance. 
 
 The microscopic changes are, first of all, a rapid 
 fall in the number of organisms per field, which in 
 several cases is apt to give place to a secondary rise 
 about the fifth or sixth day, in the absence of any 
 necrosis of bone or retention of clothing or missiles. 
 Then a change is found in the character of the cells, 
 some of which undergo cytoplasmic breakdown while 
 others show decided phagocytic activity. Then this 
 activity ceases to be manifest, and the bulk of the 
 
GUNSHOT WOUNDS AND THEIR TREATMENT 69 
 
 leukocytes undergo complete necrosis. As the wound 
 improves in appearance so do the cells become few 
 and necrotic. It is possible, Gruner suggests, that 
 the flavine penetrates into the cell substance and 
 alters its metabolism, setting up necrobiosis along 
 abnormal lines, with a resultant flooding of the tissues 
 with abnormal products of metabolism. These arrest 
 the multiplication of the microbes. There may be 
 an added inhibition of the outpouring of coagulable 
 fluids, causing the wound surface to dry up after a 
 few days. These changes appear to be more rapid 
 with proflavine than with acriflavine. Many of the 
 wounds treated with these compounds have been 
 closed by secondary suture, with results to all ap- 
 pearance identical with those which are found after 
 treatment by the Carrel or Morison methods. 
 
 Such is a brief statement of the present position 
 with regard to the treatment of war wounds. It must 
 never be forgotten that the time element is always 
 an important factor, and that the problem of dealing 
 with an early contaminated wound is not identical 
 with, indeed, may be marvellously different from, 
 that concerned with a lalte infected wound. The con- 
 ditions in the early hours, when the patients are at 
 the Casualty Clearing Stations in France, are very 
 different from those to be combated when the patient 
 
70 AMERICAN ADDRESSES 
 
 reaches a base hospital in England after the lapse of 
 many days or many weeks. Finally in the English 
 army, with the channel and the long train journey 
 interposed between the hospitals in France and those 
 at home, a new and very difficult set of circumstances 
 must be taken into account. 
 
 But wherever and whenever the patient is seen, 
 the most urgent desire and the paramount concern 
 of the surgeon is to secure closure of the wound. 
 Whatever mode of dressing is adopted, whatever pro- 
 cedure, whether of physiological or of antiseptic prin- 
 ciple, is trusted, it is the suture of the wound at the 
 earliest opportune moment that must be the goal of 
 every effort. 
 
 So far as our present knowledge will allow us to 
 formulate conclusions, the following deductions may 
 usefully be drawn: 
 
 Perfect mechanical cleansing, that is, the excision 
 of all contaminated, infected, or dead parts, the re- 
 moval of all fragments of clothing (by far the most 
 important of all causes of continuing infection in a 
 wound) and of all projectiles, is the supreme necessity 
 in all cases. 
 
 In early cases, when there has been little or no loss 
 of tissue, this may allow of immediate closure of the 
 
GUNSHOT WOUNDS AND THEIR TREATMENT 71 
 
 wound, which will be followed by healing in the ma- 
 jority of cases, say in 70 per cent, or 80 per cent. 
 
 In infected early cases the mechanical exposure 
 and cleansing may be followed by a treatment di- 
 rected to the removal of the remaining infection. 
 Physiological and antiseptic methods each have their 
 advocates. The aim of both is to permit of the 
 earliest prudent secondary closure of the wound. In 
 infected late cases a thorough mechanical exposure 
 and cleansing of the wound and the parts around will 
 allow of secondary closure forthwith if certain anti- 
 septic pastes are used. Experience shows that similar 
 results have sometimes followed upon this thorough 
 mechanical treatment of the wound without the in- 
 troduction of antiseptics. A further trial in this 
 class of cases may show that the natural defences of 
 the tissues already awakened are ample to deal with 
 the infections then remaining. Where large gaping 
 wounds are left as a result of gross destruction and 
 loss of tissue, infection is controlled and subdued 
 without suppuration to the point of "clinical sterili- 
 sation" by the application of the Carrel-Dakin 
 method. 
 
 It is the natural defensive powers of the body fluids 
 and tissues, of serum and leukocytes, that are the 
 chief agents in finally subduing the bacterial infec- 
 
72 AMERICAN ADDRESSES 
 
 tion in a wound. Sufficient reliance does not appear 
 to be placed upon the stupendous power the body 
 tissues possess for controlling infection. 
 
 Finally, full emphasis must always be laid on the 
 ^paramount necessity for the complete immobility of 
 wounded parts at all times and on all occasions. So 
 will one of the most powerful agencies making for 
 reinfection be kept constantly in check. 
 
WOUNDS OF THE KNEE-JOINT 
 
 There is probably no department of surgery in 
 which greater changes have been wrought since the 
 early days of the war than in that concerned with 
 the treatment of wounds of the knee-joint. When I 
 was first in France in November, 1914, the majority 
 of the cases of wounds of this joint exhibited, by the 
 time that a base hospital was reached, a grave sup- 
 purative arthritis; very often the patient was ex- 
 tremely ill, with a high temperature and all the evi- 
 dences of a severe constitutional infection; and in 
 a large number of cases only the most drastic pro- 
 cedures offered any hope that the limb might at 
 least be saved. Too often, perhaps, we failed to re- 
 member that a man had two legs and only one life, 
 and conservative measures were pushed to excess. 
 In the work of the French army, as I saw it, amputa- 
 tion was in such circumstances often advocated and 
 practised forthwith; and there can be no doubt, I 
 think, that though some limbs were sacrificed that 
 continued care might have saved, many lives were 
 rescued that would otherwise have been jeopardised 
 or lost. 
 
 73 
 
74 AMERICAN ADDRESSES 
 
 By degrees, however, as our grasp of surgical 
 principles grew firmer, and as transport facilities 
 increased, cases were obtained earlier, a more direct 
 and deliberate attack was made upon the wounds, 
 and results began rapidly to improve. It was 
 quickly realised that all methods of treatment of 
 a well-established purulent arthritis were miserably 
 inefficient, and that here, as elsewhere, every effort 
 must be directed to such a precocious and drastic 
 treatment of the wound as would prevent the de- 
 velopment, never long delayed, of an infection. It 
 was felt to be insufficient so to treat a limb as to 
 save it only with a stiff joint; the aims must be both 
 to save the member and to preserve the freedom of 
 movement in the damaged articulation. 
 
 For purpose of academic description the following 
 classes of injury may be recognised: 
 
 1. Cases of Clean Perforating Wound of the Knee- 
 joint by Rifle Bullet. — There are cases in which a rifle 
 bullet traverses the joint from side to side, often 
 without inflicting any damage or the most trivial 
 damage to the bone. In other cases the bullet or a 
 shrapnel ball may have entered the joint and have 
 lodged in the lower end of the femur, or in the upper 
 end of the tibia. The wound or wounds inflicted 
 may be small. They are rapidly sealed up, and pre- 
 
WOUNDS OF THE KNEE-JOEsTT 75 
 
 sent no evidences of inflammatory reaction. The 
 joint may or may not fill gradually with fluid during 
 the next few days. If fluid forms and is removed, 
 it is commonly found to be sterile. In such cases 
 conservative methods are fully justified by the re- 
 sults. The joint must be perfectly immobilised and 
 the patient retained if possible at the clearing sta- 
 tion, so as to avoid the disturbances often insepar- 
 able from travel. Aspiration of the fluid and the in- 
 jection of formalin and glycerin, formerly often 
 practised, do not seem to insure or to hasten the re- 
 covery. 
 
 2. Cases of Penetrating or Perforating Wounds of 
 the Joint with a Larger Aperture of Entry or of Exit, 
 or Both, When the Projectile is Retained in the Joint. 
 — ^All such cases must be submitted to operation. 
 The limb, which should be immobilised at the field 
 ambulance, is kept absolutely at rest until an a^-ray 
 examination is made. This is indispensable; under 
 no circumstances may a blind exploration of the joint 
 be made in the hope that the missile, if any, or if 
 many, may be discovered and removed. The sur- 
 geon must know beforehand the conditions he will 
 probably meet, and must deal with them purpose- 
 fully and deftly. 
 
 The position and size of the projectile being ascer- 
 
76 AMERICAN ADDRESSES 
 
 tained, the track of the missile must be determined. 
 The position of the Hmb as it lies on the splint is, of 
 course, hardly likely to be that which it had when 
 the wound was inflicted. 
 
 After the whole limb has been thoroughly prepared 
 in the usual manner, certain definite objects must be 
 pursued. The wounds and the track of the projectile 
 must be excised; missiles must be removed, all for- 
 eign bodies and fragments of clothing taken away, 
 and such damaged and loosened fragments of bone 
 sacrificed as may appear to be necessary. The 
 technique of wound excision is the same in these in- 
 juries as in others; the damaged skin and all the 
 bruised and lacerated track down to and including 
 the synovial membrane are removed, if possible, in 
 one piece. A preliminary sterilisation of the track 
 with the actual cautery is an undoubted advantage. 
 How, precisely, the incision is to be made will depend 
 upon the exact circumstances. A good rule for the 
 surgeon in all his technical responsibilities is that he 
 should see well what he is doing and do well what he 
 sees. These should be endeavours in the knee-joint 
 especially. 
 
 To make a small incision, and to introduce his 
 finger to "explore" the joint, which may mean to 
 grope blindly and clumsily therein, is not in accord 
 
WOUNDS OF THE KNEE-JOINT 77 
 
 with the needs of eases such as these. A quite ade- 
 quate exposure is necessary; if this can be obtained 
 by an enlargement of the aperture of entrance, or 
 of exit, or of both, nothing more is required; if it 
 cannot, then a long internal or preferably external 
 incision is made; if these are insufficient, then the 
 surgeon must make up his mind to a sacrifice of the 
 ligamentum patellae and the making of the semi- 
 circular flap fashioned in many cases of excision of 
 the knee. By the time the patient is ready to use 
 his limb the ligament will have united firmly and be 
 competent to bear the strain then placed upon it. 
 There can be no doubt, however, judging by the 
 cases I have seen, that the functional result in all 
 returns more slowly and always less perfectly than in 
 those where only the lateral incisions are made. A 
 free and full exposure of all the injured parts being 
 then obtained, the following injunctions may be ob- 
 served : to remove all dead tissue, to remove all soiled 
 parts, to remove all foreign bodies, clothing, mud, 
 clots, etc. 
 
 How strictly is the surgeon to interpret the rule 
 that all projectiles must be removed .^^ Our experi- 
 ence in England shows beyond dispute that — (a) 
 if a projectile is embedded in the articular ends of 
 the bones, when the bone has suffered little or no 
 
78 AMERICAN ADDRESSES 
 
 damage beyond that necessarily inflicted by the en- 
 trance of the foreign body, it becomes encapsulated 
 and rarely if ever gives rise to subsequent trouble; 
 and (6) if a projectile, however small, remains in the 
 knee-joint, it is an abiding source of infection and of 
 suppurative arthritis. The most troublesome and 
 tedious of all the cases seen at home are those in 
 which a foreign body has been left in the joint. It 
 is therefore a strict and necessary injunction that all 
 projectiles should be removed at the earliest oppor- 
 tunity. All vessels bleeding ever so slightly in the 
 wound are carefully secured. The wound and all 
 parts exposed are gently wiped, and if the surgeon 
 so desires, some form of antiseptic may be used — 
 ether, or Dakin's solution, or saline solution. The 
 wound is then closed by layer after layer of catgut 
 sutures until the skin is reached. For this silkworm- 
 gut is used. 
 
 Is drainage to be used.^^ In the early months of 
 the war drainage-tubes were freely, indeed almost 
 universally, employed. Sir Anthony Bowlby, how- 
 ever, had often emphasized their very real disad- 
 vantages. Unlike most surgeons, I believe, he had 
 for many years in civil practice forbidden their 
 introduction in all cases under his care. He has now 
 won all opinion around to his view. There can be 
 
WOUNDS OF THE KNEE-JOINT 79 
 
 no longer any doubt that any form of tube introduced 
 into the joint cavity in these early cases is productive 
 of nothing but evil. Tubes damage the synovial 
 membrane by their pressure, and are a potent and 
 abiding avenue of infection. As a binding obliga- 
 tion, with no objections worthy of consideration, it 
 may be asserted that tubes should never be placed 
 within the joint. It is rare to see in the base hospitals 
 in England a movable knee-joint when tubes have 
 been used within the cavity. Drainage, however, 
 may be necessary and is quite adequately secured 
 by placing tubes ''down to but not into" the joint, 
 and by leaving a gap in the line of the sutured 
 synovial membrane. The delicate tissue of the syno- 
 vial membrane then suffers no harm, yet if effusion 
 occurs, it finds a ready exit and easy escape to the 
 surface. Dressings are then applied and absolute 
 immobility secured for eight or ten days by a splint. 
 
 There a^re cases, probably between 10 and 15 per 
 cent, of the total number, treated upon these lines, 
 in which an effusion into the knee-joint, larger or 
 smaller in quantity, associated with an elevation 
 of temperature, may occur, generally after the fifth 
 or sixth day. 
 
 What is then to be done? This question is to be 
 answered by the bacteriologist and the surgeon work- 
 
80 AMERICAN ADDRESSES 
 
 ing together. An examination of the fluid discharged 
 from the tube, or removed by aspiration of the joint, 
 must be made forthwith. If any organisms but the 
 streptococcus or staphylococcus are found, there is 
 no need as yet for anxiety. In quite a number of 
 the cases the fluid will prove to be sterile and will 
 leak away by slow degrees through the aperture 
 prudently left in the synovial membrane. Day by 
 day the temperature will fall and the knee assume 
 once again its normal size, and all will at last go well. 
 If, however, the staphylococcus is found, the joint 
 must be watched almost from hour to hour. If 
 fluid is leaking away slowly and if the temperature 
 tends to fall, and if the patient remains comfortable, 
 then expectant methods may safely be continued. 
 In the great majority of such cases all anger will 
 subside and the infection will be subdued by the 
 patient's own efforts. Such cases help one to realise 
 the strength of the defensive power that the knee- 
 joint is capable of exercising. When, however, the 
 streptococcus is present, active and timely inter- 
 ference is necessary. The joint must be freely opened 
 by long lateral incisions or by semicircular incisions 
 dividing the patellar ligament. The synovial mem- 
 brane must be stitched to the skin, and the Carrel- 
 Dakin method adopted. If the infection is of a still 
 
WOUNDS OF THE KNEE-JOINT 81 
 
 graver or more hostile kind, excision of the joint 
 or even amputation may be imperatively necessary. 
 
 There are few types of cases, if, indeed, there are 
 any, which give such genuine gratification to the 
 surgeon practising in England as those treated in 
 France by methods similar to those described. A 
 very large number have now been received into our 
 base hospitals in which, a month or six weeks after 
 an injury that two or three years ago would have 
 meant permanent disablement of the joint as the 
 best attainable result, all movements of the knee 
 are free and unimpeded and attended by no pain 
 whatever. In no circumstances do we realise with 
 such certainty and satisfaction the remarkable sci- 
 entific advances made by our colleagues working 
 with the army in France. 
 
 3. Cases of Perforating or Penetrating Wounds of 
 the Joint with Intra-articular Fracture. — This condi- 
 tion is a degree more serious than that in which the 
 missile has cleanly entered and become firmly em- 
 bedded in the end of the femur or the tibia. There 
 is here a shivering of the aHicular ends, with many 
 irregular lines of fracture. In the midst of a soft 
 mass of crushed bone the projectile may be lying. 
 All such cases must be dealt with ruthlessly. There 
 must be adequate exposure by one or other of the 
 
82 AMERICAN ADDRESSES 
 
 incisions before mentioned; all dead, severely dam- 
 aged, or entirely loose fragments of bone taken away; 
 the curette or the bone forceps being used to get rid 
 of all bone which is beyond hope of recovery. As a 
 rule, the distinction between sound and doomed 
 bone is easily made. The articular cartilage is, how- 
 ever, always dealt with most sparingly. The future 
 integrity of the joint movements depends upon the 
 preservation of every undamaged scrap of this 
 structure. 
 
 It will often be found that an injury which before 
 free exposure has appeared trivial is seen, when the 
 joint is opened up, to be very extensive and to require 
 a careful and long-continued toilet before all parts 
 are cleansed and removed. It may be necessary 
 once or twice to change instruments, gloves, or towels, 
 in the due observance of the strict aseptic ritual 
 always necessary. When all parts are cleaned, the 
 most perfect hsemostasis is secured and the wound 
 then closed. 
 
 In many cases in England we have used Morison's 
 paste (Bipp) to smear over the rough osseous sur- 
 faces which remain or over a bruised or inflamed 
 synovial membrane. I have seen several cases of 
 severe infection of the knee treated by Mr. Morison 
 himself, and have been surprised some weeks later 
 
WOUNDS OF THE KNEE-JOINT 83 
 
 to see what a remarkable degree of functional res- 
 toration has been obtained. It is in these severer 
 forms of injury to the knee-joint that we have by 
 degrees been brought to realise that our old timidity 
 toward this joint is quite needless. It is no exaggera- 
 tion to say that with proper care the knee can pro- 
 tect itself from infection almost as well, if not quite 
 as well, as the peritoneum. Our fear of infections 
 within the joint was due to an ignorance of the 
 methods of treatment of them. Most surgeons deal- 
 ing with even a mild infection, and probably all sur- 
 geons dealing with anything approaching a grave 
 infection, relied upon drains introduced into the 
 cavity of the joint to rid the parts of inflammatory 
 products. We know now that nothing but harm 
 comes from a drainage-tube placed into the joint. 
 If drainage is necessary, it is secured by tubes down 
 to the synovial membrane but not within it, by 
 suturing the synovial membrane to the skin, or by 
 adopting, as Mayo Robson suggests, a special pos- 
 ture of the limb. 
 
 4. Cases of Injury to the Knee-joint, with Extensive 
 Fracture of the Articular Ends of the Bones. — The 
 practice to be followed in such cases will depend 
 upon the position and extent of the injury, the num- 
 ber and localisation of the projectiles, and the degree 
 
84 AMERICAN ADDRESSES 
 
 of infection. If there is extensive fracture without 
 loss of tissue, it is probable that an attempt to save 
 the knee will be worth while; that even if ankylosis 
 results, the firmness and strength of the limb will be 
 adequate to most purposes. When, however, there 
 is extensive localised loss, as, for example, when 
 one condyle of the femur is blown completely away, 
 then a formal resection of the knee-joint forthwith 
 is probably the best course. In such a case, even if 
 complete healing takes place, the functional utility 
 of the limb is greatly hindered by those deformities 
 which inevitably follow. As much of the femur 
 must be spared, in making the resection, as can with 
 safety be left; the upper end of the tibia, if intact, 
 must have only the merest shaving of the articular 
 cartilage excised, enough, that is, to allow a bony 
 ankylosis to take place. The amount of the two 
 bones that can be removed without serious disable- 
 ment is remarkable. I have had one patient whose 
 leg was a trifle over four inches shorter than the 
 other who walked with vigour and not inelegantly. 
 A part both of the femur and of the tibia had been 
 destroyed by a shell fire. 
 
 In cases included in this group where infection has 
 obtained a hold the method of excision introduced 
 
WOUNDS OF THE KNEE-JOINT 85 
 
 by Colonel FuUerton may be practised. Instead of 
 bringing the opposing ends of the femur and the tibia 
 together, means are taken by extension to keep them 
 apart. A wide gap then is left which may be filled 
 lightly with gauze and the Carrel-Dakin method of 
 treatment adopted. When the wound has reached 
 the stage of "clinical steriHsation," the bones may be 
 fitted together and the limb fixed in a splint. 
 
 In still more than severe types of injury amputa- 
 tion of the thigh is performed without delay. This 
 counsel is especially urgent when the great vessels 
 also are injured, when laceration of the soft parts is 
 extensive, and when infection, especially with the 
 bacillus of gas gangrene, is evident. 
 
 CONCLUSIONS 
 
 1. In all cases of wounds of the knee-joint the limb 
 should be fixed immovably upon a splint at the 
 earliest possible moment, and until circumstances 
 and surroundings permit of a complete operation. 
 
 2. At the Casualty Clearing Station, or other oper- 
 ating centre, an x-rsiy examination is made in all 
 cases. The whole limb is then prepared for opera- 
 tion. 
 
 3. The following are the essential features in all 
 operations: excision of the wounds and of the track 
 
86 AMERICAN ADDRESSES 
 
 of the projectile after preliminary sterilisation by the 
 cautery or otherwise; a free exposure of the joint, 
 either by enlarging existing incisions or by long in- 
 ternal or external incisions or by the formation of a 
 flap by division of the patellar ligament. 
 
 4. All foreign bodies must be removed from the 
 joint. Even the smallest piece of clothing or of metal 
 may be the nidus of a continuing infection. 
 
 5. The wounds are closed in layers by catgut su- 
 tures. Drainage is secured by leaving a gap in the 
 line of suture of the synovial membrane, or by leav- 
 ing a tube close "down to but not into" the joint. 
 
 6. Drainage-tubes are never placed within the 
 joint cavity. They do not drain the joint; they are 
 harmful in their effects upon the delicate synovial 
 membrane, and they are often a channel by means 
 of which infection is conducted to the joint. 
 
 7. In cases of severe infection of the joint by 
 staphylococcus, or especially by the streptococcus, 
 the wounds must be reopened, the synovial membrane 
 stitched to the skin, free drainage of the joint secured, 
 and the Carrel-Dakin or other method of progressive 
 sterilisation of the wound adopted. In more severe 
 cases, with an infection rapidly gaining ground, ex- 
 cision of the joint may be necessary. 
 
WOUNDS OF THE KNEE-JOINT 87 
 
 8. In cases of severe comminution of the articular 
 ends with much loss of substance (the whole of one 
 condyle, for example) a resection of the joint is per- 
 formed forthwith. 
 
 9. In severe and extensive wounds with heavy in- 
 fection the method of resection with wide, temporary 
 separation of the ends of the bones (Fullerton) should 
 be practised. 
 
 10. In cases of very extensive damage, especially 
 with infection, amputation is desirable. 
 
 The following record, made by Colonel Gilbert 
 Barling, C. B., of the work done at a group of base 
 hospitals in France, though many months old, may 
 still be quoted with interest : 
 
 1. Total cases of injury to knee operated 
 
 on 845 
 
 2. With bone injury 438 
 
 3. Without bone injury 407 
 
 4. Wound excised and closed 322 
 
 5. Cases under (4) requiring further oper- 
 
 ation 82 = 25.5 per cent. 
 
 6. Wound excised and packed 336 
 
 7. Cases under (6) requiring further oper- 
 
 ation 128 = 38.4 
 
 8. Excision of knee 42 
 
 9. Artkrectomy, partial or complete 15 
 
 10. Excisions or arthrectomies amputated . 13 = 22.8 " 
 
 11. Deaths after excision or arthrectomy . . 13 = 22.8 " 
 
 12. Amputation without excision 151 
 
88 AMERICAN ADDRESSES 
 
 13. Deaths under class 12 49 = 32.4 per cent. 
 
 14. Total amputations 164 = 19.4 
 
 15. Total mortality 72= 8.5 
 
 Note. — One hospital with a large number of cases was un- 
 able to separate the cases under items 4 and 6. 
 
ON INJURIES TO THE PERIPHERAL NERVES 
 AND THEIR TREATMENT 
 
 In the preparation of this paper I have received valuable 
 help from my colleagues on the staff of the Second Northern 
 General Hospital, Leeds, Captain Burrow, Captain Daw, Cap- 
 tain Richardson, and Dr. Cuthbert Morton. 
 
 NATURE OF INJURIES 
 
 The lesions of nerve-trunks as the result of wounds 
 inflicted in war may be of diverse forms : 
 
 I 
 
 In the majority of cases the nerve-trunk has not 
 sustained a primary injury. It may be exposed in 
 greater or less degree in a wound of the soft parts 
 with or without fracture. If the wounds are gravely 
 infected and suppuration occurs with, perhaps, ne- 
 crosis of one or of many fragments of bone, the proc- 
 ess of healing may be long delayed, and the cicatri- 
 cial tissue which results will be of exceeding density. 
 The nerve then may come to lie in the midst of a 
 fibrous mass which, undergoing progressive contrac- 
 tion, presses more and more firmly upon the delicate 
 and tender tissue of the nerve. The nerve-trunk is 
 
 89 
 
90 AMERICAN ADDRESSES 
 
 strangled, bereft of its due supply of blood, and be- 
 comes in consequence functionless. It is impossible 
 before operation to decide in the severer cases whether 
 such a nerve has or has not been completely divided. 
 
 II 
 
 The nerve-fibres may not have been directly, or 
 they may have been only very trivially, implicated, 
 but the projectile may have passed so near the nerve- 
 trunk as to have opened its sheath. The nerve then 
 becomes adherent to the track of the missile, and a 
 mass of fibrous tissue is found firmly welded on to its 
 lateral aspect. Or the projectile, in this case a rifle 
 or machine-gun bullet, may at that period of its flight 
 when it has become steady have cleaved through the 
 trunk of a nerve, separating the fibres and severing 
 few or none. Haemorrhage within the sheath occurs, 
 and a fibrous mass develops in the centre of the nerve, 
 causing it to assume a fusiform appearance. There 
 is, then, a central neuroma. 
 
 Ill 
 
 The nerve may have been partly severed, say in 
 half its diameter, by a projectile or a fragment of 
 bone. The gap in the nerve is soon filled up by fibrous 
 tissue, which extends widely upward and downward 
 
INJURIES TO THE PERIPHERAL NERVES 91 
 
 and away from the side of the nerve, so that a hard 
 fibrous lateral neuroma is found. 
 
 IV 
 
 The nerve may be completely severed. In such a 
 case a gap of greater or less length is found between 
 the divided ends. Bridging this interval there may 
 be a connecting strand of fibrous tissue, or a blurred 
 mass of scar material in which both cut ends are lost. 
 In some cases the nerve may appear hard and swollen, 
 and as though its fibres were continuous ; but careful 
 dissection will show that there is complete division. 
 
 When the nerve has been cut completely across, the 
 upper divided end is soon found to present a charac- 
 teristic bulbous appearance. On section this is seen 
 to consist partly of fibrous tissue and partly of nerve 
 tissue. From the upper end of any divided nerve the 
 axis-cylinders grow downward tirelessly, each one 
 searching out diligently but blindly the lower end to 
 which it seeks to unite. When the quest fails in one 
 direction and an uncongenial tissue is met, the axis- 
 cylinder turns in another direction, searching there 
 fruitlessly again, and so twists itself in ceaseless con- 
 tortion until a tumour — Siterminal neuroma — ^is formed. 
 
 The fibrous mass, often of extreme density, which 
 goes to the making of the bulbous end is probably the 
 
92 AMERICAN ADDRESSES 
 
 reply of tissues to the contact of exposed nerve-fibres 
 with them. The peripheral nerves are intruders 
 among the other tissues of a limb, reaching them by a 
 process of invasion from without. The contact of 
 these nerve-fibres with any other tissue is prevented 
 by their closure within a sheath whose function ap- 
 pears to be that of an insulator. The end organs of 
 the sensory nerves may indeed be, as W. Trotter 
 suggests, a special mechanism for isolating the nerve- 
 fibres, protecting them from actual contact with the 
 tissues. Whenever the nervous system is injured, by 
 accident or design, as in the operations of trephining 
 and laminectomy, there is always a hasty and ade- 
 quate attempt to isolate the parts again. There is an 
 intolerance of the tissues for contact with nerve 
 matter or, conversely, of these with other tissues. 
 
 Gosset says that the axis-cylinder is very unintel- 
 ligent. I am not sure that its search for the distal 
 end is stupid because it is unsuccessful. The search 
 is zealous enough, but the axis-cylinder shrinks from 
 ignoble contact with a baser tissue, and turns aside 
 to seek elsewhere. 
 
 The lowered severed end becomes thickly covered 
 with a fibrous cap which forms a barrier impenetrable 
 by the axis-cylinders seeking so earnestly to find their 
 way along the distal nerve. 
 
INJURIES TO THE PERIPHERAL NERVES 93 
 
 1. THE NERVES INJURED; RELATIVE FREQUENCY 
 The relative frequency of affected nerves has in our 
 experience been as follows: 
 
 Per Cent. 
 
 Musculospiral 25 
 
 Ulnar 24 
 
 Median 14 
 
 Sciatic 12 
 
 External popliteal 12 
 
 Internal popliteal 1 
 
 Upper portion of the brachial plexus 4 
 
 Lower portion of the brachial plexus (cords) 7 
 
 Anterior crural 1 
 
 This corresponds fairly accurately to the experience 
 recorded by Gosset and by Tinel. 
 
 2. DIAGNOSIS 
 The following points in the clinical histories are 
 investigated : 
 
 Date of injury. 
 Nature of projectile. 
 Position of patient at moment of injury. 
 Immediate effects. 
 
 After-history (including history of operations per- 
 formed) . 
 Physical examination consists in — 
 
 A. Inspection of the limb to note — • 
 
 1. Attitude, contractures (claw hand, etc.). 
 
 2. Position of wounds and scars. 
 
94 AMERICAN ADDRESSES 
 
 B. Testing of the Efferent Impulses. 
 
 1. Motor weakness for paralysis, each muscle 
 and each muscle group tested separately. 
 
 2. Trophic and vasomotor disturbances. Non- 
 shedding of epidermis, "glossy skin," ulcers, 
 changes in nails, etc. 
 
 3. Changes in deep tissues, for example, muscu- 
 lar atrophy, fibrillation, bone decalcification, 
 etc. 
 
 C. Testing of the Afferent Impulses. 
 
 1. Pain, its character, distribution, relation to 
 hot and cold applications or weather. 
 
 2. Loss of cutaneous sensibility, tested by stan- 
 dardized stimuli of special instruments so that 
 results are strictly comparable. 
 
 Light touch. 
 
 Localisation of spot touched. 
 
 Tactile discrimination (pressure, texture, etc.). 
 
 Stereognostic sense (size and shape of three 
 dimensions); appreciation of compass 
 points applied simultaneously. 
 
 Thermal stimuli (hot and cold test-tubes). 
 
 Painful stimuli (pinprick controlled by stan- 
 dardized spring). 
 
 Roughness (Graham Brown sesthesiometer). 
 
 3. Deep sensibility. 
 Pressure pain. 
 Vibration sense in bones. 
 Joint and muscle sense, etc. 
 
INJURIES TO THE PERIPHERAL NERVES 95 
 
 Electrodiagnosis 
 
 The reactions to the interrupted current are tested 
 by shocks from an induction coil, the electrode being 
 placed upon the "mator point" of each muscle in 
 turn. The current from a secondary coil is always 
 used. 
 
 A positive reaction to faradism is regarded as a 
 contraindication to operation, but failure to respond 
 gives no definite information, for voluntary move- 
 ment may return, after nerve injury, before the 
 f aradic response. 
 
 The muscles are next investigated by a constant 
 current. "Polar changes" have been found to be of 
 minor value; they may vary with the local circula- 
 tory changes following massage, etc. The character 
 of the contraction is of much more importance. A 
 brisk twitch indicates the probable presence of some 
 conducting nerve-fibres in the muscle tested, while 
 a slow "vermicular" response is usuajly associated 
 with a complete interruption of nerve-fibres. 
 
 The nerve muscle is next examined by means of a 
 condenser discharge. The method depends upon the 
 fact that a condenser discharge through a constant 
 resistance gives a current which varies in duration 
 according to the capacity of the condenser used. 
 
 The more severe the damage to the nerve, the 
 
96 AMERICAN ADDRESSES 
 
 greater will be the capacity of the condenser required 
 to excite it. Or, in other words, the longer the dura- 
 tion of the current, the more chance is there of ob- 
 taining a response in such a nerve muscle. The whole 
 advantage of the condenser method is that a definite 
 measurement of current or condenser used may be 
 noted, and future progress may be accurately fol- 
 lowed. 
 
 The condenser method is chiefly used in cases 
 where operation is deferred because some function 
 is found to be present in a given injured nerve. (The 
 work done recently by E. D. Adrian and others shows 
 that the condenser is disappointing in practice; but 
 it nevertheless gives useful information in recording 
 progress.) 
 
 Complete absence both of faradic and galvanic 
 response is an indication for early operation. The 
 cases which require careful and repeated examinations 
 are those where there is pressure on the nerve-trunk 
 by a contracting scar. In some nerve-trunks there 
 is little damage to some of the fibres, with total loss 
 in others. Operation must not be deferred too long 
 in these cases, because the fibres with complete re- 
 action of degeneration may never recover on account 
 of a dense scar tissue formation at the site of injury. 
 In other words, the presence of a degree of volun- 
 
INJURIES TO THE PERIPHERAL NERVES 97 
 
 tary power in some individual muscles of a group 
 supplied by a damaged nerve is no sure criterion 
 that the paralysed muscles will recover without 
 operation. 
 
 It is most important that nerve injuries should be 
 reexamined at frequent intervals and carefully de- 
 tailed records of motor power, sensory changes, and 
 electrical reactions kept. In this way treatment 
 may be modified according to progress. 
 
 In operations upon nerves where a diagnosis of 
 total loss in some fibres only has been made it is our 
 practice to test the exposed nerve both above and 
 below the site of injury at the time of operation. 
 
 For this examinaition special sterilisable electrodes 
 and long connecting cords which can be boiled are 
 used. The nerve is gently lifted upon two small 
 glass hooks and a very weak faradic current em- 
 ployed. 
 
 The most accurate anatomical arrangement of 
 fibres may be noted by this means and the knowl- 
 edge used to secure perfect adaptation in nerve suture. 
 The diagnosis is often completed during a period 
 in which massage, baths, and electrical treatment are 
 employed to improve the local circulation, and splint 
 treatment adopted to relax affected muscle groups 
 and to overcome contractures. The distinction be- 
 
 7 
 
98 AMERICAN ADDRESSES 
 
 tween anatomical and physiological division is not 
 made before operation. 
 
 DIFFICULTIES IN DIAGNOSIS 
 The main difficulties encountered in arriving at an 
 exact diagnosis are in cases where there are : 
 
 Wasting and stiffness from disuse. 
 
 Circulatory disturbances. 
 
 Contractures. 
 
 Destruction or adhesion of muscle and tendon. 
 
 Operation is decided upon in the following circum- 
 stances : 
 
 1. In cases of complete division. 
 
 2. In cases of incomplete division, where progress 
 is arrested. 
 
 3. Where there is severe neuralgic pain, "causal- 
 gia." 
 
 Operation is deferred — 
 
 1. For one month after the closure of the wound 
 where soft parts only are injured. 
 
 2. For two or three months after complete closure 
 of the wound where bone has been involved. 
 
 3. Definitely so long as progressive signs of re- 
 covery in nerve functions continued. 
 
 The suture of the nerve may have to be delayed 
 until unsatisfactory joint conditions are improved. 
 
INJURIES TO THE PERIPHERAL NERVES 99 
 
 Contractures of the knee, for example, should be 
 corrected before the sciatic nerve is sutured, other- 
 wise the nerve would be in danger of rupture if the 
 deformity were subsequently rectified. 
 
 In other cases the nerve may be sutured and the 
 joint dealt with at the same period and subsequently. 
 
 It is of the first importance to start active measures 
 to prevent or remove stiffness and deformity in the 
 parts supplied by a wounded nerve. This can often 
 be done for many weeks before it is possible to repair 
 the nerve. It is not sufficiently realised that a nerve 
 to be of use after suture must act upon live and supple 
 tissue. Joints and muscles must be kept ready for 
 the nerve impulse which some day will come to them 
 again. 
 
 OPERATIONS 
 
 When the diagnosis of a nerve lesion requiring 
 operation has been made, the earliest prudent oc- 
 casion must be chosen for operation. In both the 
 French and British armies nowadays the suture of a 
 divided nerve is performed in those most advanced 
 operating centres where the first deliberate toilet 
 of the wound is possible. It is realised, of course, 
 that very often a complete union between the severed 
 ends cannot result, but even if the operation prove 
 eventually to be a complete failure, the subsequent 
 
100 AMERICAN ADDRESSES 
 
 operative procedures are certainly easier, and it is 
 a satisfactory thought that a chance has been given 
 for heaHng to take place. 
 
 In the great majority of nerve lesions dealt with 
 up to recent times the wound inflicted by the pro- 
 jectile has suppurated. We have learned by bitter 
 experience in this war what this means. It means 
 that the bacterial flora in such a wound are numer- 
 ous, and potentially, at least, of great malignancy. 
 It means that even a simple operation upon a wound 
 which still discharges pus may arouse a flaming in- 
 fection and be a cause of tetanus or gas gangrene. 
 Mere passive movement of a joint grown stiff by 
 inactivity may bring about an attack of tetanus even 
 though the adjacent wound has healed. In many 
 cases an injury to bone may have been inflicted at 
 the same moment as the division of the nerve; this 
 is, of course, frequently the case when the musculo- 
 spiral nerve is implicated. Many loose pieces of 
 bone may remain as sequestra in the wound and may 
 need removal or may escape spontaneously from time 
 to time. In all such cases operation upon the nerve 
 must be deferred until the wound has been soundly 
 healed for some weeks ; no rule is more binding upon 
 the surgeon than that. During this period, which 
 may be protracted, the most diligent attention must 
 
INJURIES TO THE PERIPHERAL NERVES 101 
 
 be given to the limb, especially to those parts, mus- 
 cles and joints, distal to the injury. The paralysed 
 muscles must be kept in a position of relaxation. 
 This may be easy, as in those cases where the mus- 
 culospiral nerve is divided; it is often difficult, as 
 in cases of injury to the median nerve; it is some- 
 times impossible, as in dual or triple lesions of nerve- 
 trunks. But, difficult or easy, the best possible must 
 be done, for the final functional result in respect of 
 quality and of rapidity depends in no small degree 
 upon the early care of the parts deprived of their 
 nerve supply. 
 
 Special and unremitting attention is given to the 
 joints, which must always be kept supple. It is re- 
 markable how quickly the fingers, for example, be- 
 come so stiff that forced movement is an agony. 
 Every day, many times a day, all the paralysed parts 
 must be freely moved to their full range, and the 
 patient must be instructed to attend to this matter 
 unceasingly. The most perfect nerve healing is 
 robbed of its value if, through long disuse, the muscles 
 whose innervation is restored have lost their power 
 to act, and if the joints are so firmly ankylosed that 
 even passive movement cannot bend them fully. 
 The value of these preliminary and preparatory 
 measures cannot be overestimated. 
 
102 AMERICAN ADDRESSES 
 
 When the operation actually takes place it is im- 
 portant to observe certain essentials to success. 
 There must be the most perfect and scrupulous 
 asepsis and the most gentle handling. The finger 
 should never be placed in the wound. All dissec- 
 tions should be carried out deftly and neatly with a 
 very sharp knife, in the "feather edge" method of 
 Crile; the most diligent care must be taken never to 
 bruise the nerve by seizing it, however gently, in 
 forceps. The nerve must never be twisted, or torn 
 or stretched, or unduly separated from its bed. 
 Other structures must be dissected from the nerve: 
 the nerve must not be dissected from them. The 
 nerve must not be stripped bare for too long a dis- 
 tance, otherwise it will be devascularised, and re- 
 cuperative processes will be slow or absent. The 
 wound as a whole, and the nerve in particular, must 
 not be allowed to dry or to be chilled. The most 
 dainty and precise movements are necessary through- 
 out, and every bleeding point must be thoroughly 
 secured. There are, of course, the observances that 
 go to make up the ritual of every well-trained sur- 
 geon; their strict acceptance is more necessary here 
 than in almost any other operation, if the most rapid 
 and the most flawless recovery is to be made certain. 
 
 As a rule, a tourniquet is undesirable, for two rea- 
 
INJURIES TO THE PERIPHERAL NERVES 103 
 
 sons. It is possible to harm the nerve, or other nerves 
 in the Hmb, if the rubber band is apphed too tightly, 
 and for the long period sometimes necessary in this 
 procedure; and when the operation is complete and 
 the tourniquet removed, there will probably be an 
 escape of blood into the wound — a thing in these 
 cases most undesirable. In these wounds not in- 
 frequently there is a good deal of young fibrous tissue, 
 from which free oozing may occur in the period of 
 hypersemia which follows removal of a tourniquet. 
 
 The incision is designed to fall on the skin at some 
 distance from the original wound if possible; very 
 often a flap will occur from the making of a curved 
 incision. The planning of the incision gives scope 
 for one's knowledge of anatomy; it is so arranged 
 that no small nerves are wounded. Major Jamieson 
 has shown that when the median nerve is injured in 
 the forearm it may sometimes be more thoroughly 
 and successfully dealt with from the outer instead 
 of from the inner side of the flexor carpi radialis. 
 So, too, when the musculospirail nerve has been in- 
 jured high up on the outer side of the forearm. Dr. 
 Cuthbert Morton suggests that instead of cutting 
 through the outer head of the triceps it should be re- 
 flected complete from the humerus. Not only does 
 this cause less damage to the muscle tissue, but it 
 
104 AMERICAN ADDRESSES 
 
 also exposes the nerve and its branches, as well as 
 the profunda artery, to a very high level without 
 undue risk. 
 
 The nerve-trunk is sought above and below the 
 point of severance, and is traced downward and up- 
 ward to the gap. Swift, neat little cuts with a very 
 sharp scalpel damage the tissue to the smallest pos- 
 sible degree. The surgeon must avoid contact of 
 his fingers with the wound: it is clumsy and inar- 
 tistic to prod about among muscles in the hope of 
 feeling the nerve. It is his business to know before 
 he begins these operations exactly where the nerve 
 lies, and he should always be able to cut directly 
 down on it. When the injured part of the nerve is 
 exposed, it is usual to find a bridge of fibrous tissue 
 between the ends, the proximal end being often very 
 turgid and bulbous. If the gap between the refreshed 
 ends of the nerve is likely to be wide, now is the time 
 for stretching the nerve, so as to lessen the interval 
 as much as possible. This is done with infinite gentle- 
 ness and care by seizing the fibrous band between the 
 ends and drawing steadily upward and downward, 
 always remembering to make the pull in the line of 
 the nerve-trunk and to avoid twisting. The fibrous 
 band is now split longitudinally, and then its ends 
 are divided above in one direction, below in the 
 
INJURIES TO THE PERIPHERAL NERVES 105 
 
 Other, so that to each cut end of nerve a fibrous tag 
 is attached, by means of which the nerve-ends can be 
 drawn together. Progressive transverse cuts are now 
 made into the nerve-ends until on the cross-section 
 nothing but nerve-fibres are seen. Every tiniest 
 particle of fibrous tissue must be removed or the 
 operation will fail. The axis-cylinders coming from 
 above must have free entry into the nerve below, 
 otherwise in their downward development they will 
 lose their way, and restoration of the nerve function 
 will not take place. When the nerve-ends are duly 
 prepared, they are brought into apposition with the 
 greatest care. A series of very fine catgut sutures 
 holding only the nerve-sheath are inserted at inter- 
 vals around the circumference of the nerve. A suture 
 is never passed through the substance of the nerve 
 itself. In uniting the nerve-ends it is of the first im- 
 portance to avoid axial rotation. We know now that 
 there is a differentiation of function within each 
 nerve, and it is, therefore, strictly necessary to unite 
 corresponding bundles of fibres. A nerve does not 
 act as a whole, but consists of a multitude of strands 
 each with its proper and restricted function. Unless 
 nerve bundles which were originally continuous are 
 brought accurately together by suture, the nerve is 
 compelled to rearrange the functions of its several 
 
106 AMERICAN ADDRESSES 
 
 parts. This it can and no doubt frequently has to 
 do. An examination of manj^ cases shows, however, 
 that a perfect and flawless recovery after a nerve 
 suture is unusual, and it is at least a tenable belief 
 that this inadequacy or delay in recovery is due to a 
 want of recognition by the surgeon of all that is 
 needed in the technical part of the operation. My 
 colleagues on the staff of the Second Northern Gen- 
 eral Hospital in Leeds are obtaining results which in 
 rapidity and completeness would have been thought 
 impossible before the war. 
 
 There is rarely any difficult}^ in obtaining accuracy 
 of apposition without tension. If, however, the nerve- 
 ends cannot readily be brought together, various 
 procedures may be adopted to shorten the course of 
 the nerve. The nerve may be dislocated from its 
 bed and laid in a new and shorter line. The ulnar 
 nerve, for example, may be brought to the front of 
 the inner condyle. Or flexion of the limb may be 
 enough to allow of easy approximation. In the case 
 of the median nerve divided low in the forearm, 
 flexion of the wrist will give an inch or more addi- 
 tional reach. In other cases the limb may be short- 
 ened by removing an inch or two of bone. It is de- 
 sirable to avoid a subcutaneous course in all trans- 
 ferences to new positions. The nerve after suture 
 
INJURIES TO THE PERIPHERAL NERVES 107 
 
 should be brought to lie in a bed of healthy tissue. 
 It must be placed between muscles, and away from 
 all contact with new connective tissue, which will 
 adhere to it and hinder its union, or cripple its sub- 
 sequent action. 
 
 It has been the fashion with many surgeons to sur- 
 round the sutured nerve with some material supposed 
 to have protective virtues. A piece of a vein — the 
 saphenous, for example— is threaded over the upper 
 cut end of the nerve before suture, and after these 
 ends are approximated the vein is drawn downward 
 and made to surround the line of suture. In other 
 cases a piece of fat dissected from near the wound, 
 or from another part, is wrapped around the nerve, 
 fat being supposed to be capable of insulating the 
 nerve in its new position, or a layer of fascia may be 
 used, or a piece of Cargile membrane. The value of 
 all such methods is open to serious question; it is 
 certain that they are sometimes harmful : it is doubt- 
 ful if they ever help. They prevent access of blood 
 to the nerve by new channels; they cause adhesions 
 and compression of the nerve, and at times they are 
 discharged from the wound almost unaltered. It is 
 better to avoid such membranes, and to be content 
 with insuring that the nerve is laid along the path of 
 uninjured tissues. Where end-to-end suture is im- 
 
108 AMERICAN ADDRESSES 
 
 possible, a variety of other procedures may be at- 
 tempted. A nerve graft, taken from a neighbouring 
 cutaneous nerve — from the radial, the internal cuta- 
 neous of the thigh, or an intercostal nerve — may be 
 used. Experience on the human subject has not yet 
 enabled me to determine the value of this procedure. 
 In experimental work it answers well, but I have 
 rarely, if ever, seen a result which could be claimed 
 as satisfactory. Colonel Mayo-Robson has had one 
 of the very few successful cases.* Nerve anastomosis 
 has been tried in a number of cases. The divided 
 ends of a nerve are implanted into the side of a near- 
 lying nerve, the ulnar into the median, for example. 
 This has been done both with and without section of 
 the nerve-fibres of the intact nerve. All such proce- 
 dures are worthless, and cannot be too strongly con- 
 demned. I have never seen any good come of them; 
 indeed, nothing but harm could conceivably result 
 from section of a healthy nerve. And if it is allowed, 
 as it must be, that a nerve consists of many separate 
 strands, each with its own special and exclusive func- 
 tion, it is certain that permanent damage is inflicted 
 by this method. There is no justification for this 
 procedure nowadays, and it should be cast out among 
 forgotten things. Lengthening of the nerve by turn- 
 * British Medical Journal, 1917, i, p. 117. 
 
INJURIES TO THE PERIPHERAL NERVES 109 
 
 ing down a strand from the upper divided end and the 
 bridging of the gap by strands of catgut, are methods 
 with nothing whatever to recommend and everything 
 to discredit them. 
 
 Happily the resources of surgery are not at an end 
 in all cases where union of divided nerves is impos- 
 sible. Tendon transplantation, especially in the case 
 of the musculospiral nerve and the posterior interos- 
 seous, gives results which, in point of function, are 
 almost as good as those which come from nerve su- 
 ture, and in point of time are much quicker. It is 
 chiefly in the musculospiral nerve that large gaps are 
 found, a piece of the nerve having been blown com- 
 pletely away. In such cases tendon transplantation 
 gives excellent and speedy results. When the pos- 
 terior interosseous nerve is wounded it is not worth 
 while attempting to suture the nerve. The results 
 in such cases are slow, and not always perfect. 
 
 In those cases where the nerve is partly divided, 
 strands of intact fibres still remaining, the severed 
 fibres are united in the same careful way, and the 
 normal strand of the nerve bent upon itself, so as to 
 allow easy approximation of the cut portions of the 
 nerve. In perhaps the majority of operations upon 
 nerves there is no division of fibres, but a length of 
 the nerve is embedded in dense fibrous tissue. These 
 
110 AMERICAN ADDRESSES 
 
 cases give most excellent results. The fibrous tissue 
 which so intimately surrounds the nerve is dissected 
 away little by little. The nerve when first freed is 
 seen to be white and shrunken; but within a few 
 minutes it expands and takes on its normal colour. 
 I had several cases of this kind in the Boer war, and 
 the results at this long interval are perfect. It is in 
 these cases that advantage may sometimes be taken 
 of the method of fat transplantation or of nerve dis- 
 location. 
 
 AFTER-TREATMENT 
 
 1. Postural 
 In cases where flexion of a joint has been necessary 
 to allow approximation of the cut ends of nerves, the 
 position is maintained for a period of six weeks. By 
 this time union of the severed ends is probably well 
 advanced. Extension by slow and most cautious 
 degrees is then begun. If the knee has been flexed to 
 allow the sciatic nerve to be united, the patient can 
 walk with a boot and leg irons, keeping the position 
 unaltered for, say, two months. Wherever possible 
 a splint is applied which produces a "relaxation posi- 
 tion." In the case of the median and ulnar this is 
 difficult, and is best, secured by molding a "ball 
 splint" to the hand of the patient. Every such splint 
 must be made for the individual. In the case of the 
 
INJURIES TO THE PERIPHERAL NERVES 111 
 
 musculospiral it is very simple. The "cock-up" 
 splint designed by Colonel Sir Robert Jones is excel- 
 lent if the lesion of the nerve is below the branch to 
 the supinators. It maintains hyperextension of the 
 wrist, and, reaching only to the heads of the meta- 
 carpal bone, it allows a forward bend of the meta- 
 carpophalangeal articulations. The thumb lies for- 
 ward and a little inward, so that the position of the 
 whole hand is very much that assumed when a bottle 
 is grasped. If the lesion is above the nerve to the 
 supinator brevis, it is essential that this muscle also 
 should be relaxed. For this purpose Dr. Cuthbert 
 Morton has devised a splint which retains the fore- 
 arm and hand in supination while the wrist is fully 
 extended, the fingers being at the same time kept in 
 the bottle-grasping position. 
 
 Similarly in cases of injury to the external popliteal 
 nerve relaxation of the corresponding muscles may 
 be secured by the boot which ha^ been introduced by 
 Dr. Cuthbert Morton in order to allow the patient 
 to walk about with the foot in permanent dorsi- 
 flexion. 
 
 2. Massage and Electrical Treatment 
 These measures are restarted about two weeks after 
 operation with all due precautions and safeguards. If 
 
112 AMERICAN ADDRESSES 
 
 a splint has been applied to secure the "relaxation 
 position," it must not be removed. Indeed, not for 
 one moment at any time must paralysed muscles be 
 stretched. An overstretching of a few minutes may 
 call for diligent treatment of many weeks before the 
 harm is undone. If a splint needs removal for pur- 
 poses of cleanliness, the patient must be instructed 
 beforehand to kqep the limb in the exact position 
 required. In the case of musculospiral palsies the 
 hand drops into the correct position if the flexor sur- 
 face of the forearm is upward. 
 
 RESULTS 
 Our records are as yet necessarily incomplete. Re- 
 covery in the case of the musculospiral has begun 
 within nine weeks; in the case of the ulnar within 
 three and a half months; in the case of the median in 
 about four to five months. In one case of division 
 of the inner cord of the brachial plexus recovery in 
 all ansesthetic areas and a degree of recovery in all 
 muscles occurred within five months. Recovery in 
 the case of the sciatic nerve is slower. Something 
 depends, it is sometimes said, upon the length of 
 time elapsing between division of the nerve and its 
 suture. My colleague. Captain Richardson, has, how- 
 ever, united the ends of an ulnar nerve cut across 
 
INJURIES TO THE PERIPHERAL NERVES 113 
 
 fifteen years before and signs of returning function 
 were seen in about four months. The duration of the 
 disability is, therefore, no bar to successful repair of 
 the nerve. 
 
 The functions return usually in the following order: 
 
 1. Trophic and vasomotor function. 
 
 2. Deep sensibility. 
 
 3. Tactile discrimination and localization. 
 
 4. Motor power. 
 
 5. Cotton- wool sensation. 
 
 Perfect restoration of function has been most nearly 
 approached in the case of the musculospiral nerve. 
 In other nerves with more complex distribution per- 
 fect recovery will depend upon a recognition of the 
 functional localization within the nerve-trunk, in ad- 
 dition to the most scrupulous observance of all those 
 technical details without which there will always be 
 something less than perfection. 
 
 In the diagnosis and treatment of an organic lesion 
 of a nerve it should never be forgotten that there may 
 be superadded a functional disability. It is advisable 
 at every stage to get rid of the functional in order 
 properly to appreciate the organic. This is particu- 
 larly important when the organic lesion is well on 
 the way to recovery. Thus, in a recovering lesion of 
 the inner cord of the brachial plexus it may be im- 
 
114 AMERICAN ADDRESSES 
 
 possible for the fingers to be flexed until reeducation 
 has trained the laggard muscles into obeying orders 
 from headquarters. 
 
 SUMMARY 
 
 The following summary may be given of our ex- 
 perience up to the present time: 
 
 1. The earliest examination should be made of all 
 wounds in which division of a nerve-trunk is prob- 
 able. If at the Casualty Clearing Station such a 
 lesion is found, end-to-end suture should be adopted 
 forthwith. This is more likely to be possible in cases 
 where primary suture of the wound, after excision, 
 is found practicable. 
 
 2. If secondary suture of the wounds, after the 
 Carrel-Dakin method has been practised, is to be 
 undertaken, the union of divided nerves should be 
 secured at the same time. 
 
 3. If these methods have been attempted and have 
 failed, they do not prejudice the later union of the 
 nerve. On the contrary, they probably insure that 
 an easier and more satisfactory operation can then 
 be practised. 
 
 4. Throughout the whole period before late nerve 
 suture is attempted the strictest attention must be 
 paid to the relaxation and nutrition of all paralysed 
 
INJURIES TO THE PERIPHERAL NERVES 115 
 
 muscles, to the maintenance of suppleness in all 
 joints moved by these muscles, and to the preser- 
 vation of the integrity of the skin. 
 
 5. Operations upon nerve-trunks demand the most 
 scrupulous observance of the ritual of asepsis. There 
 must be the greatest gentleness of manipulation; the 
 nerve must not be injured by instruments or by the 
 surgeon's finger; it must not be separated from its 
 sheath or disturbed overmuch from its bed; it must 
 not be chilled or allowed to dry. All sutures must be 
 of fine catgut, and introduced with most punctilious 
 accuracy. Axial rotation of the nerve must be 
 avoided. The cut ends of the nerve before approxi- 
 mation must show clearly the fibres of which the trunk 
 consists. 
 
 6. Nerve-grafting is of little or no value; nerve 
 anastomosis is to be sharply condemned; the turning 
 down of flaps from the nerve to bridge a wide gap is 
 useless. 
 
 7. Tendon transplantation is of great value in cases 
 where nerve suture is impossible, or has given a re- 
 sult not entirely satisfactory. 
 
GUNSHOT WOUNDS OF THE LUNGS AND 
 PLEURA 
 
 The mortality of chest wounds In all zones of the 
 army is extremely difficult to ascertain with any- 
 thing approaching accuracy. Pierre Duval, whose 
 work on the surgery of the lungs during this war has 
 been characterised by originality, insight, prudent 
 courage, and great technical success, has gathered 
 together the records from many points of the French 
 army. Of a total of 3455 cases, there were 688 
 deaths — roughly, a mortality of 20 per cent. But the 
 mortality differs, as may well be imagined, at vari- 
 ous parts of the line of communications. At the aid 
 posts it is terrible — ^not less, it is asserted, than 25 
 to 30 per cent. At the ambulance chirurgical auto- 
 mobile, or Casualty Clearing Stations, the mortality 
 is about 18 to 20 per cent. In the base hospitals 
 the death-rate is about 10 per cent. There is, it will 
 be seen, a progressive diminution in mortality from 
 the front to the base. P. Duval scrutinized these 
 figures in the following remarkable way : 
 
 At the aid post, where the mortality is 25 per cent., 
 
 117 
 
118 AMERICAN ADDRESSES 
 
 there will remain alive, of 100 patients, 75. At the 
 ambulance, of these 75, 20 per cent, will die and there 
 will remain 60 patients. At the base of these 60, 
 10 per cent, will die, so that finally 54 cases will 
 survive. 
 
 Two series of cases falling under individual ob- 
 servation may be quoted. Gregoire records a total 
 of 404 cases of chest wounds, pure and simple, with 
 47 deaths — a death-rate of 11.7 per cent. Of these, 
 57 patients were operated upon for empyema, with 
 resection of the rib and drainage; 26 died — a mor- 
 tality of 45 per cent. 
 
 Depage, at his well-known hospital at La Panne, 
 which combines the functions of Field ambulance. 
 Casualty Clearing Station, and Base Hospital, re- 
 ceiving patients a few hours after injury and retain- 
 ing them as long as is necessary, records 320 cases of 
 pure chest injury with 59 deaths, that is, 18.4 per 
 cent. Within the first twenty -four hours 9.4 per 
 cent, of cases died, chiefly from haemorrhage. In the 
 later stages 10 per cent, of the survivors died, chiefly 
 from sepsis. 
 
 Elliott* estimates the mortality of chest wounds in 
 the British army in France, at the field ambulances, 
 and Casualty Clearing Stations at from 20 per cent. 
 ♦Lancet, 1917, ii, 371. 
 
GUNSHOT WOUNDS OF LUNGS AND PLEURA 119 
 
 to 25 per cent., of which 10 per cent, to 15 per cent, 
 are the early result of shock and haemorrhage, and of 
 which 10 per cent, die of sepsis. The mortality on the 
 lines of communication is about 5 per cent. ; all these 
 deaths are from sepsis. The mortality of cases reach- 
 ing England is small. 
 
 All observers are agreed that there is a difference 
 in the mortality according to the nature of the pro- 
 jectile inflicting the injury. If a rifle bullet causes the 
 wound, the condition resulting is either very serious 
 if a large vessel is struck, or very benign if the lung 
 tissue is traversed without serious vascular injury. 
 Wounds from high explosive shell, the fragment 
 causing the wound being irregular and jagged, the 
 pieces of clothing or of skin being driven deeply in, 
 are always serious by reason of the infection that was 
 so prone to follow. Rouvihois, in 102 cases, found 
 the following: 
 
 In 60 cases where the projectile was retained there 
 were 27 deaths; in 26 of these the wound was caused 
 by shell, in 1 case by rifle bullet. In 42 cases of per- 
 forating wounds there were 10 deaths; in 9 of these 
 the wound was caused by shell and 1 by rifle bullet. 
 These are truly remarkable comments upon the 
 influence of the projectile in determining the mor- 
 tality. 
 
120 AMERICAN ADDRESSES 
 
 Death occurs chiefly from two causes : from haemor- 
 rhage and from sepsis. Haemorrhage is fatal early — 
 generally within the first twenty-four or forty-eight 
 hours. Sepsis proves fatal at a later stage — generally 
 from the seventh day onward. The most fatal cases 
 are those where there is a gaping wound of the chest, 
 so that the lung is freely exposed. The mortality 
 in cases where the chest-wall is closed behind the 
 projectile is rather less than one-half of that which 
 results when there is an open wound. Captain H. 
 Henry, in 100 postmortem examinations made upon 
 patients with chest wounds who reached a base hos- 
 pital in France, found that the great majority of 
 deaths were due to septic infection. Only four pa- 
 tients died from haemorrhage, and in three of these 
 the haemorrhage was secondary in character and was 
 induced by sepsis. 
 
 PATHOLOGICAL ANATOMY 
 
 The injuries inflicted by a projectile entering the 
 chest may be considered in relation to their effects 
 upon: 
 
 (a) The chest-wall. 
 
 (6) The injured lung. 
 
 (c) The opposite lung. 
 
 The Chest-wall. — The damage done to the chest- 
 
GUNSHOT WOUNDS OF LUNGS AND PLEURA 121 
 
 wall may be of the most diverse forms. There may- 
 be a clean penetration of the thorax from front to 
 back, the projectile, in this case a rifle bullet, cleav- 
 ing a way through all the tissues it meets here, pre- 
 cisely as it does when the thigh or the soft parts any- 
 where are pierced. In many of these cases, however, 
 and in a still larger number when there is a shell- 
 wound, there is a fracture of one or more of the ribs 
 or of the scapula. Fragments of bone, tiny spicules, 
 or larger pieces are carried into the chest, and at a 
 later operation may be recognised and removed 
 either from the lung itself or from the pleural cavity, 
 especially in the cul-de-sac above the diaphragm. 
 The same results follow this scattering of the bone 
 into the lung as occur when there is a compound 
 fracture of the long bones in the limbs. Each bony 
 sequestrum becomes itself a projectile driven with 
 force into the tissues, and carrying with it a capacity 
 for infection, and inflicting a grave injury upon all 
 the parts through which it tears its way. The condi- 
 tions so produced are serious and long continued. 
 
 In severer cases a part of the chest-wall may be 
 destroyed, being driven inward by a massive piece 
 of shell casing, or being swept away by a glancing 
 blow. Few cases reach a base hospital in France, 
 and still fewer, of course, in England, when any large 
 
122 AMERICAN ADDRESSES 
 
 part of the parietes has been lost. Such cases die in 
 advance stations up the line from shock or from 
 haemorrhage. The few that I have seen at base hos- 
 pitals were all heavily infected and suffered much 
 distress. Their condition is a powerful argument in 
 favour of the early closure of all parietal wounds, 
 wherever possible. 
 
 The Injured Lung. — The effects produced in the 
 lung are strictly comparable to those produced in 
 other parts of the body by the various forms of pro- 
 jectile. The points of entrance and of exit in the 
 case of perforating wounds bear all the appearances 
 of those seen in the soft tissues of the thigh. The 
 entrance wound is small, even punctate; the orifice 
 of exit is large, more irregular, and bears signs of 
 greater injury and of a tendency to protrusion of 
 wounded parts. Along the track of the missile there 
 are the same evidences of diffused injury. The parts 
 around are bruised and lacerated; there is a haemor- 
 rhagic pulmonary infiltration of varying but often 
 wide extent. The part of the lung giving on to the 
 track is contused or dead, and such tissue offers here 
 as elsewhere the most favourable opportunities for 
 bacterial invasion and growth. Postmortem ex- 
 aminations of wounded lungs generally show that the 
 track of the projectile, whatever it may have been, 
 
GUNSHOT WOUNDS OF LUNGS AND PLEURA 123 
 
 is rectilinear. There are no fissures or rifts radiating 
 from the main track, nor any hidden pockets shut 
 off from the central channel. Several tracks may be 
 found in close approximation when many fragments 
 of metal have entered. The bronchi of large or 
 medium size seem to escape injury in the majority 
 of cases. In the path of the projectile blood is ex- 
 travasated in the earliest hours; in later stages pus 
 may be found. 
 
 The injury to the damaged lung is not, however, 
 confined to the path of the bullet and the parts im- 
 mediately adjacent. The distant parts of the lung 
 or the pleura bear traces of lesions, due to the force 
 with which the parts are struck or to the sudden 
 constriction of the chest, followed by its instant 
 expansion, upon the impact of a volume of com- 
 pressed air caused by the explosion of a shell. There 
 may be haemorrhages by "cont recoup" in the upper 
 lobe if the lower is wounded, or in the lower if the 
 upper is injured, or in both if the projectile has 
 passed near the base of the lung. These, as Duval 
 has shown, may be recognised at once by the opa- 
 city seen on the radiograph; and I have found 
 in later operations many recent adhesions of the 
 pleura over parts that could by no possibility have 
 met with a direct assault and evidences of intrapul- 
 
124 AMERICAN ADDRESSES 
 
 monary hsemorrhages. These conditions are of the 
 same order as those described in an early fatal case 
 by Latarket. He has found a massive congestion of 
 the whole lung, a sort of diffuse hsemorrhagic infiltra- 
 tion involving the entire organ, in a case in which a 
 bullet wound was inflicted at close range. 
 
 Such meagre postmortem experience as exists 
 confirms the impression that is derived from the 
 clinical examination of operated cases, that wounds 
 of the lung heal rapidly and kindly. 
 
 The Opposite Lung. — It is a new fact, learned 
 during this war, that the opposite lung suffers damage 
 also. Such lesions are frequent, in the severer cases 
 probably constant. They consist in small or large 
 hsemorrhages beneath the pleura or in the substance 
 of the lung. These may be followed by filamentous 
 or by firm adhesions between the visceral and 
 parietal pleura and by patches of solidity in the 
 lung itself. In a late stage the lung may present 
 all the evidences of a bronchopneumonia at one 
 point or in many. The increased activity imposed 
 upon the lung by the restricted function of that which 
 has been wounded no doubt renders it an easy prey 
 to any malady. The presence of an infected expec- 
 toration in the trachea may lead to the inhalation of 
 purulent or septic material into the uninjured lung. 
 
GUNSHOT WOUNDS OF LUNGS AND PLEURA 125 
 
 These conditions often improve very rapidly when 
 the injured side is treated by aspiration of a large 
 hsemothorax, or free drainage of an empyema. 
 
 Haemorrhage. — When a missile enters or traverses 
 the chest, any of the vessels contained therein may be 
 lacerated. If the larger vessels in the mediastinal 
 cavities or in the root of the lung are divided, the 
 loss of blood is so copious and rapid that death re- 
 sults at once and the patient does not reach even an 
 advanced aid post. 
 
 In the cases not immediately fatal the blood comes, 
 in the very great majority of cases, from the lung 
 tissue. Henry and Elliott, as a result of careful in- 
 vestigation of the thoracic walls and the lung in 78 
 postmortem examinations made on the subject of 
 hsemothorax, came to the conclusion that the bleed- 
 ing had been of pulmonary origin in the great ma- 
 jority of cases. 
 
 Apart from the cases dying instantly from haemor- 
 rhage, the deaths in the first forty-eight hours are all 
 due to loss of blood from lung tissue. Both in the 
 French and the English armies precocious operative 
 measures are being adopted in such cases with a de- 
 gree of success that encourages a wide adoption of 
 this practice. If death does not occur speedily from 
 haemorrhage, a recurrence of bleeding is not often 
 
126 AMERICAN ADDRESSES 
 
 seen. Patients rarely die from haemoptysis, and 
 secondary haemoptysis is extremely infrequent. The 
 occurrence of haemorrhage through the wounds of 
 entry or of exit is probably responsible for the errone- 
 ous belief that it is from the chest-wall, from the 
 intercostal vessels, that the blood is lost. 
 
 Dolbey records one very remarkable case of gross 
 haemorrhage resulting from a wound of the axillary 
 vein. The chest filled with blood from the torn ves- 
 sel, but after two large aspirations, the wound in the 
 vein healed. There was also an aneurysm of the 
 axillary artery treated by ligation of the subclavian 
 artery successfully. 
 
 Hgemothorax. — When blood escapes into the pleural 
 cavity, what happens to it.^ According to Elliott 
 and Henry, "it appears probable that clotting always 
 takes place — and very early — through the action on 
 the blood of the ferment liberated at the surface of 
 the wounded tissues; the clot may be (a) complete 
 and massive, forming a soft and persistent clot; (b) 
 massive, but with an early and fairly extensive sepa- 
 ration of the yellow serum from the clot; (c) interfered 
 with by the churning movements of respiration'* 
 (and of the heart. ^), "so that the fibrin is whipped out 
 in layers which cover the pleural surfaces, while the 
 serum retains most of the red corpuscles in suspen- 
 sion." 
 
GUNSHOT WOUNDS OF LUNGS AND PLEURA 127 
 
 The amount of blood extravasated into the pleura 
 varies very much — from a few ounces up to four or 
 even five pints. The escape of blood is hindered and 
 at last arrested by collapse of the lung and by the 
 pressure exerted by the blood which has already 
 flowed into the pleural cavity. The response of the 
 pleura to the contact of blood is expressed in an in- 
 flammatory reaction which also helps in some degree 
 to seal the leaking orifice, though it also increases 
 the mass of fluid lying in the chest. In fact, the ad- 
 mixture of fluid effused from the pleura accounts for 
 the fact that in many cases the condition of the com- 
 bined fluids does not conform with that seen when 
 only blood is extravasated. 
 
 Hsemothorax in itself, though disabling enough 
 and productive of such general effects as the loss of 
 a large quantity of blood necessarily entails, is not 
 dangerous to life, apart from infection. The bacteria 
 chiefly responsible for this hazardous complication 
 are, according to Duval : 
 
 1. Derived from the respiratory tract: 
 Pneumococcus. 
 Staphylococcus. 
 B. tetragenus. 
 B. of Pfeiffer. 
 
 2. Derived from the wound: 
 Streptococcus. 
 B. coll. 
 
 A. Aerobic 
 
128 AMERICAN ADDRESSES 
 
 Bacillus of Welch. 
 
 B. Anaerobic -, „ 
 
 B. sporogenes. 
 
 The most common association is of the Bacillus 
 coli with the gas gangrene bacillus. 
 
 The frequency of infection may be gauged from the 
 figures given by Captain Henry. Out of 500 speci- 
 mens of fluid obtained by tapping, in the ordinary 
 routine of work 195 were found to be infected, and 
 of these, 87 were infected by anaerobic organisms. 
 These may be distributed from the first throughout 
 the bulk of fluid, or they may be retained in the 
 fibrinous mass at the bottom of the pleura for a longer 
 or shorter period, being disseminated at last through 
 the supernatant fluids as a result of the respiratory 
 movements. This accounts for the fact that the first 
 puncture made for diagnostic purposes was found by 
 Elliott and Henry in 50 per cent, of pure infections 
 by anaerobic bacilli to be negative. The syringe 
 introduced into the upper fluid part of the hsemo- 
 thorax may discover no organisms, whereas one made 
 lower down, into the more solid fibrinous clot, may 
 give positive results. The infection may be derived 
 from the projectile or clothing carried into the wound 
 at the moment of the infliction, or may be derived 
 at a later stage from the focus in the lung or from the 
 suppurating external wound. P. Duval, in the 
 
GUNSHOT WOUNDS OF LUNGS AND PLEURA 129 
 
 Somme battles, had charge of 193 cases of gunshot 
 wound of the chest. Of these, 49 were due to bullet 
 wounds, none of them had an infected hsemothorax, 
 there were 33 perforating wounds from shell frag- 
 ments, and among these were 6 of infected hsemo- 
 thorax — 18 per cent. There were 111 penetrating 
 wounds; among these were 28 of infected haemothorax 
 (24 per cent.). 
 
 TREATMENT 
 
 Upon one point all those who have been respon- 
 sible for the treatment of a patient with a chest 
 wound are in complete and confident agreement. The 
 earliest and the most perfect immobilisation is neces- 
 sary. Movements of all kinds are to be avoided, and 
 therefore retention of the wounded man at the Cas- 
 ualty Clearing Station for many days is a paramount 
 necessity. The fact that in the first two days the 
 deaths are due chiefly to haemorrhage and in later 
 stages to sepsis must direct the timely and appro- 
 priate treatment. Early operations for the purpose 
 of arresting haemorrhage from the lung tissue have 
 been tried out in certain hospitals in either the French 
 or the British zones; but so far as the results of the 
 work have gone, they appear to justify a continuance 
 of, and indeed a general adoption of, the principle 
 
130 AMERICAN ADDRESSES 
 
 of early direct treatment of the wound. It is, I 
 think, largely owing to the advocacy and to the suc- 
 cessful practice of P. Duval that an earlier surgical 
 attack is now considered necessary upon the graver 
 kind of lung case. 
 
 Immediate intervention, according to Duval, should 
 comprise : 
 
 I. Closure of the chest- wall in cases of "open 
 thorax." 
 
 II. Thoracotomy with suture or plugging of the 
 wound in the lung in case of grave haemorrhage or 
 of threatening asphyxia. 
 
 III. Treatment of progressive surgical emphysema. 
 
 I. Closure of the chest-wall, an operation prac- 
 tised by Larrey in the Napoleonic wars, has as its 
 aim the suture of the muscles and skin in order to 
 avoid traumatopnoea, pneumothorax, and a continu- 
 ing infection of the pleura from the suppurating ex- 
 ternal wound. The principles are those guiding the 
 surgeon in all similar wounds elsewhere; the results 
 in the saving of life and suffering are incalculable. 
 The gravity of the cases of '*open thorax" can hardly 
 be exaggerated. When a part of the chest-wall has 
 been torn away the lung, often bruised or lacerated, 
 is exposed, it retracts toward the hilum, and leaves 
 gaping and bare a huge cavity wherein putrefaction 
 
GUNSHOT WOUNDS OF LUNGS AND PLEURA 131 
 
 may occur and a large surface from which absorption 
 can take place. It is most urgently necessary to close 
 such ghastly wounds if it is physically possible. 
 Gregorie has accomplished this in 17 cases, of whom 
 16 recovered. 
 
 II. Thoracotomy is formally indicated in all cases 
 of wound of the lung causing haemorrhage. Suture of 
 the lung tissue affords perfect hsemostasis. When any 
 foreign body, projectile, or sequestrum is felt, the 
 lung is incised over it if necessary, and after extrac- 
 tion of the foreign body, the wound is stitched up 
 accurately. Any blood lying in the pleura is care- 
 fully evacuated, perfect cleansing of the cavity is 
 insured, and the wound is closed, it may be after a 
 gentle wiping of the parts with ether. There is no 
 need for drainage. 
 
 III. In the treatment of progressive emphysema 
 closure of the wound in the lung will shut off the chan- 
 nel through which the air escapes into the tissues. 
 Multiple skin incisions will relieve the tissues already 
 distended and crepitant. In cases of simple penetrat- 
 ing wounds a cleansing and excision of the wounds, 
 followed by a complete approximation of the edges, 
 is all that is necessary. In many cases even excision 
 is not required; the points of entrance and of exit may 
 be cleaned and covered with a sterile dressing. 
 
132 AMERICAN ADDRESSES 
 
 When a hsemothorax is present, no interference, as 
 a rule, is needed for some days. There may be ex- 
 ceptions to this rule when the rapid or the large ac- 
 cumulation of fluid is causing urgent dyspnoea which 
 threatens the life of the patient. The dangers of 
 early aspiration of the fluid are, of course, related 
 to the reopening of the pulmonary wound, which, 
 lightly sealed, may bleed afresh as the lung expands. 
 At the end of a week or thereabouts aspiration of the 
 blood has probably a most beneficial effect upon the 
 lung, allowing it to expand much more rapidly than 
 would otherwise be possible, and preventing the for- 
 mation of those dense crippling adhesions which may 
 embarrass the free action of the lung for a long time 
 to come, or even permanently. Operations on cases 
 in England, in which the blood has been left in the 
 pleural cavity, reveal an extreme density and a wide 
 extent of adhesions. X-ray examination also demon- 
 strates the firm union that is formed between the 
 two layers of the pleura. Withdrawal of the fluid 
 is therefore most desirable; its replacement during 
 aspiration by oxygen allows more fluid to be taken, 
 and causes the minimum of distress to the patient. 
 
 In cases of large hsemothorax which presumably 
 have remained sterile, and in which no active treat- 
 ment has been adopted, there is a protracted period 
 
GUNSHOT WOUNDS OF LUNGS AND PLEURA 133 
 
 of incapacity of the lung. I have seen such cases 
 many months after the injury in which the percus- 
 sion-note was still dull, the breath-sound was absent 
 or diminished, the chest flat, and the respiratory 
 movements very restricted. On examination by 
 x-ray a greatly thickened pleura was diagnosed and 
 immobility of the diaphragm observed on the affected 
 side. If aspiration is performed, the appearance of 
 the fluid gives valuable information as to its condi- 
 tion in respect of bacterial infection. If the fluid 
 closely resembles new port wine in colour, it is free 
 from infection; if it is clear and almost colourless, the 
 amount of blood contained is small; most of the fluid 
 is then the result of a pleuritic effusion. A turbid 
 fluid like weak cocoa, or an effusion with any suspi- 
 cion of offensiveness, indicates that infection is pres- 
 ent and that the condition is one to be treated as an 
 empyema. 
 
 When a hsemothorax has become infected, then 
 thoracotomy is necessary. In the early period of the 
 war the operation was practised on the lines of the 
 civil operation for empyema. A short piece of rib 
 was excised, the putrid and most offensive fluid evac- 
 uated, and a large drainage-tube introduced. Such 
 cases remain sometimes for weeks, even for months, 
 in the open wounds. Tuffier has modified profoundly 
 
134 AMERICAN ADDRESSES 
 
 for the better the treatment of these tedious and most 
 trying cases by adapting to their needs the Carrel- 
 Dakin technique. The operation, in so far as resection 
 of the rib and evacuation of the fluid are concerned, 
 is precisely similar to the procedure in cases of em- 
 pyema, but instead of one large tube, several small 
 tubes threaded with wire are placed over the cavity 
 at well-judged intervals. Their position and proper 
 distribution may be confirmed if an x-ray is taken. 
 A little loose gauze is packed into the wound, and a 
 safetjT^-tube for drainage of excess fluid in one angle 
 of the incision. Dakin's fluid is instilled in the usual 
 manner. At the end of ten days all discharge (there 
 is rarely more than an extremely small quantity after 
 the first two days) has ceased, and the tubes are 
 therefore removed and the wound closed. 
 
 There is no doubt that many cases of suppurating 
 haemothorax would do better if operated upon quite 
 eai'ly by a wide opening of the chest and a complete 
 clearing away of all masses of clot and pleural lymph, 
 often so tenaciously adherent, and by removal of any 
 projectiles. Patients so operated upon or operated 
 by the older methods linger on in unsatisfactory con- 
 ditions for such long periods at home that every fair 
 opportunity that offers for curtailing the tedious and 
 not wholly safe period of their convalescence must be 
 
GUNSHOT WOUNDS OF LUNGS AND PLEURA 135 
 
 embraced. The Carrel-Dakin technique will here 
 find one of its most valuable indications. This is 
 only to bring the treatment of wounds of the lung 
 into line with that of wounds elsewhere. The sur- 
 geon no longer allows infection to be well established 
 in the wound; his aim is to attack by approved 
 methods [the free opening of the wound, the excision 
 of all dead or contaminated tissue, the removal of 
 all fragments of clothing, of all projectiles, and of 
 all foreign bodies] and then to secure the earliest 
 possible closure of the wound which remains. No 
 less an ideal and no less scrupulous a practice should 
 guide him also in the treatment of wounds of the 
 lung and pleura. The time has gone by when he can 
 justly allow an infection to become deeply ingrained 
 before adopting those tardy, incomplete, and often 
 ineffective methods with which he has been too long 
 content. 
 
 What is the history of patients in whose lungs pro- 
 jectiles are retained.^ Our knowledge does not allow 
 us as yet to answer this question fully. But a cer- 
 tain experience is not likely to be changed by a larger 
 survey of cases. We may say with confidence that 
 a rifle bullet or a small piece of shell casing may be 
 retained for months or years without causing distress 
 and without affecting appreciably the normal func- 
 
136 AMERICAN ADDRESSES 
 
 tions of the lung in which it lies buried. But with 
 large or irregular pieces of shell the case is different. 
 I have seen many patients suffering for twelve or 
 eighteen months from cough, with haemoptysis at in- 
 tervals. In two cases the loss of blood was serious. 
 And in many patients there is an increasing complaint 
 of pain, dyspnea on exertion, and of expectoration of 
 mucus. 
 
 For these reasons I have recently given special at- 
 tention to these patients and have submitted a num- 
 ber of them to operation. The results so far entitle 
 me to say that it is probably a safer, and it is certainly 
 a speedier, procedure to submit all patients in whose 
 lungs a large projectile is retained to operation rather 
 than to leave them untreated. In almost every case 
 operated upon the projectile has been dropped at 
 once into a culture-medium: with one exception all 
 missiles were infected; the organism most commonly 
 found was the staphylococcus. 
 
 The following are the details of the procedure 
 adopted for the extraction of bullets from the lung. 
 Its principles have been firmly established by the 
 work of Pierre Duval. The operation is performed 
 under anaesthesia induced by ether and oxygen. A 
 preliminary injection of morphin and atropin is 
 given about half an hour before the operation. 
 
GUNSHOT WOUNDS OF LUNGS AND PLEURA 137 
 
 The patient lies flat on his back, with the arms at 
 the sides. A curved incision, about 5 or 6 inches in 
 length, is made exactly along the line of the fourth 
 rib. The fibres of the pectoralis major are split, and 
 the pectoralis minor is separated from the rib. There 
 are many points of haemorrhage requiring a clip or a 
 ligature. All must be carefully secured so that there 
 is a perfectly dry field. The rib and the costal carti- 
 lage are exposed for a distance of not less than 5 
 inches. An incision is made through the periosteum, 
 midway between the upper and lower borders, and 
 this membrane is stripped from the rib on both sur- 
 faces. A curved raspatory of Doyen's pattern is 
 very useful for the purpose. In my earlier operations 
 I cut through the costal cartilage and then divided 
 the rib with forceps so that a length of 4 to 5 inches 
 of the rib could be removed. In later operations I 
 have freed the inner end of the rib after division of 
 the cartilage, have passed a strip of gauze beneath 
 it, and pulled it upward and outward, causing a 
 fracture, often of the "greenstick" type, a little be- 
 hind the middle of the rib. In this way the rib may 
 be saved and replaced at the end of the operation. 
 This, however, is not a point of great importance, 
 for when the periosteum is left, a new rib is formed 
 very rapidly, and the chest-wall soon becomes as 
 
138 AMERICAN ADDRESSES 
 
 firm as ever. Care is taken in excising the rib and in 
 lifting it away not to wound the pleura, which must 
 be separated widely from the ribs above and below, 
 to the inner and the outer side of the wound. Unless 
 this is done, accurate closure of the pleura later on, 
 always difficult, will be impossible. A retractor is 
 now placed in the wound to widen the interval be- 
 tween the ribs above and below. Any abdominal 
 retractor will do, but the best instrument I have used 
 is that invented for this special purpose by Tuffier. 
 As wide a gap as possible is made, so that the whole 
 hand can easily be passed into the chest. 
 
 The pleura is now incised along the line of the rib, 
 and air enters freely and at once into the pleural 
 cavity. As a rule, this causes no disturbance and does 
 not alter the rate of the respirations or of the pulse. 
 
 The hand is now passed into the chest cavity. 
 Adhesions of the lung to the parietal pleura may be 
 encountered. These are sometimes very slender and 
 easily broken through. At times they are tough and 
 strong and are with great difficulty severed. If they 
 are numerous or thick and tough, bleeding may occur 
 quite freely for a minute or two. With gentle pres- 
 sure from a hot, moist swab the oozing is soon 
 checked. In a case where a projectile was in the base 
 of the right lung posteriorly, the whole of the lower 
 
GUNSHOT WOUNDS OF LUNGS AND PLEURA 139 
 
 lobe and a great part of the upper lobe were most 
 intimately adherent to the parietal pleura and 
 patches of the lung felt solid. The adhesions, how- 
 ever, separated in just the same way as adhesions 
 within the abdomen separate, by gentle pressure and 
 stripping. Thoracic adhesions bleed, I think, far 
 more freely than those encountered in the abdomen. 
 When all are loosened, the collapsed lung lies free 
 within the pleural cavity. It may now be seized with 
 the fingers or with a special light form of clip and 
 drawn up to the anterior wound, and, little by little, 
 be coaxed out of the wound. It is surrounded, as it 
 appears, by warm cloths soaked in normal saline 
 solution. When a lobe of the lung is freely delivered, 
 it is palpated from top to bottom. Any projectile 
 embedded in it is felt, as a rule, at once. Even 
 little sequestra blown in from a rib may be recog- 
 nised without any difficulty. These foreign bodies 
 are as easily recognised as the particles of gritty 
 sand in a new sponge. When the projectile is felt, 
 the part of the lung containing it is made prominent, 
 the lung tissue lying over it is incised, the metal re- 
 moved, and the wound sutured. Deep stitches of 
 catgut are passed through the lung substance, and 
 with gentle tension act as a haemostatic. If neces- 
 sary, very fine catgut sutures may be used to secure 
 
140 AMERICAN ADDRESSES 
 
 the accurate apposition of the pleural edges. If 
 there is any bleeding from the collapsed lung, it is 
 slight and easily controlled, but precision in suture is 
 most desirable, for expansion of the lung will rapidly 
 be secured when the operation is completed. If there 
 are two or more particles of shrapnel or shell casing 
 in the lung, they are all dealt with in the same way. 
 I have once incised the hilum of the lung and stitched 
 it up without difl&culty. When the sutures are com- 
 pleted, the lung is replaced, the cavity of the pleura 
 most carefully dried and emptied, and a gauze swab 
 wet with ether wiped over the visceral pleura and over 
 any adhesions which may have been separated. The 
 retractor is removed and the parietal pleura now 
 stitched up. This is quite the most difficult part of 
 the operation; indeed, I have not been able to close 
 the pleura accurately unless this membrane has been 
 stripped up freely from the chest-wall before being 
 incised. The rib, if it has been turned back, is re- 
 placed, and fixed in position by a suture through the 
 costal cartilage. The muscles are carefully sutured, 
 and the wound edges accurately approximated with- 
 out drainage. The closure of the wound should be 
 so carefully done as to seal the chest hermetically. 
 When the dressing is applied, a two-way needle may 
 be plunged into the chest, and the ether and air ex- 
 
GUNSHOT WOUNDS OF LUNGS AND PLEURA 141 
 
 tracted therefrom. The lung then rapidly expands, 
 and faint breath-sounds are heard at once. 
 
 CONCLUSIONS 
 
 The following general conclusions may be stated: 
 
 1. The approximate mortality from gunshot 
 wounds of the chest at all parts of the line of com- 
 munication is 20 per cent. 
 
 2. The causes of death are haemorrhage, as a rule, 
 within forty-eight hours, and sepsis after the fourth 
 or fifth day. 
 
 3. The local conditions in wounds of the chest-wall 
 and lung are in all respects similar to those met with 
 in wounds elsewhere. The missiles are the same, 
 their destructive effects upon the tissues are the same, 
 and the infecting organisms are the same. 
 
 4. The lung tissue is more resistant to attack than 
 are many other tissues. The opening of the pleural 
 cavity and the resulting exposure of a large serous 
 sac to infection and all its consequences add, how- 
 ever, a danger of the most threatening character. 
 
 5. The chief essential in the treatment of all cases 
 of penetrating wounds of the chest is rest. 
 
 6. In clean perforating wounds of the chest rest, 
 together with the cleansing and dressing of the wound 
 
142 AMERICAN ADDRESSES 
 
 of entrance or exit, will lead to the recovery of the 
 great majority of cases. 
 
 7. In cases of "open thorax" the earliest and most 
 complete effort possible must be made to secure 
 closure of the wound after an appropriate toilet. 
 
 8. In those rare cases of grave haemorrhage, when 
 haemoptysis is present or when the blood escapes by 
 the wound, a direct access to the source of the bleed- 
 ing must be obtained, when all contingent circum- 
 stances permit, and the wound in the lung must be 
 treated by suture, preferably, or by plugging of the 
 cavity from which the blood escapes. 
 
 9. In cases of hsemothorax, when the blood effused 
 is small in quantity and remains sterile, no active 
 measures are necessary unless absorption is long de- 
 layed. Aspiration, repeated, if necessary, may then 
 be performed. 
 
 10. In cases of hsemothorax, when the blood effused 
 is large in amount and remains sterile, aspiration 
 after the seventh or eighth day, or earlier in cases of 
 urgent dyspnoea, certainly hastens convalescence, per- 
 mits a more rapid expansion of the lung, and prevents 
 the formation of firm adhesions which may perma- 
 nently cripple the free movements of the lung. 
 
 11. In cases of hsemothorax, whether the amount 
 of blood is small or large, when infection takes place. 
 
GUNSHOT WOUNDS OF LUNGS AND PLEURA 143 
 
 open operation is necessary. Early operation, espe- 
 cially of the Carrel-Dakin technique, if adopted, saves 
 many weeks of tedious convalescence and permits of 
 a more perfect functional recovery. 
 
 12. Small foreign bodies or rifle bullets embedded 
 in the lung often cause no symptoms : they become 
 encapsulated and may safely be left. 
 
 13. Larger foreign bodies retained in the lung may 
 cause distressing or disabling symptoms for long 
 periods. In such cases removal after resection or 
 elevation of the fourth rib through an anterior inci- 
 sion will allow of the safe removal of the projectile 
 from any part of the lung. Pieces of metal so re- 
 moved are generally infected. 
 
SAUNDERS* BOOKS 
 
 Skin, Genito-Urinary, 
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 Stelwa^on on the Skin 
 
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 with 356 text-cuts and ^^ plates. Cloth, ;^6.5o net. 
 
 Eighth Edition published November, 1916 
 
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SAL'XDERS' BOOKS ON 
 
 Schamberg's Diseases of the 
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 Diseases of the Skin and Eruptive Fevers. By Jay 
 
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 THIRD EDITION— published September. 1915 
 
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 Johns Hopkins Hospital Bulletin 
 
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 Asher's Chemistry ^ Toxicology for Nurses 
 
 Chemistry and Toxicology for Nurses. By Philip Asher, 
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GENITO- URINA RY D /SEASES. 
 
 Norris' Gonorrhea in Women 
 
 Gonorrhea in Women. By Charles C. Norris, M. D., 
 Instructor in Gynecology, University of Pennsylvania. With an 
 Introduction by John G. Clark, M. D., Professor of Gynecology, 
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 A CLASSIC 
 
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 occurring in men, women, and children. Published May, 1913 
 
 Coolidg'e on Nose and Throat 
 
 Manual of Diseases of the Nose and Throat. By Algerno^t 
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 READY REFERENCE 
 
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SAUA'DERS' BOOKS OX 
 
 Braasch's Pyelography 
 
 Pyelography (Pyelo=Ureterography). By William F. 
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 296 PYELOGRAMS 
 
 This new work is the first comprehensive collection of pyelograms ever 
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 O^den on the Urine TWrd Edition 
 
 Clinical Examination of Urine and Urinary Diag- 
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 net. PubUshed October, 1909 
 
 "We consider this manual to have been well compiled ; and the author's own 
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 Vecki's Sexual Impotence FifthEdiuon 
 
 Sexual Impotence. By Victor G. Vecki, M. D. 
 i2mo volume of 400 pages. Cloth, $2.25 net. 
 
 "A scientific treatise upon an important and much neglected subject. . . . The 
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DISEASES OF THE EYE. 
 
 DeSchweinitzV 
 Diseases of the Eye 
 
 The New (8th) Edition 
 
 Diseases of the Eye : A Handbook of Ophthalmic 
 Practice. By G. E. deSchweinitz, M. D., Professor of 
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 Published June, 1916 
 
 WITH 386 TEXT-ILLUSTRATIONS AND 7 COLORED PLATES 
 
 Dr. deSchweinitz"s book has long been recognized as a standard authority 
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 deSchweinitz has subjected his book to a most thorough revision. Many 
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 The text is fully illustrated with black and white cuts and colored plates, 
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 Johns Hopkins Hospital Bulletin 
 
 " No single chapter can be selected as the best. They are all the product of a finished 
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 deSchweinitz and Holloway on Pulsating' 
 
 E^XOphthalmOS published August, 1908 
 
 Pulsating Exophthalmos. An analysis of sixty-nine cases not pre- 
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 Illustrated Dictionary 
 
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 SECOND EDITION— published November, 1915 
 
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DISEASES OF THE EVE. 
 
 Haab and DeSchweinitz's 
 External Diseases qf the Eye 
 
 (Published February, 1909) 
 
 Atlas and Epitome of External Diseases of the Eye. 
 
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 A Text=Book of Modern Otology. By John F. Barn- 
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 in any other work on otology. Great pains have been taken with the illus- 
 trations. A large number represent the best work of Mr. H. F. Aitken. 
 
 Frank Allport, M. D., 
 
 Professor of Otology, North'MCstcrn Utih'crsity, Chicago. 
 
 "I regard it as one of the best books in the English language on this subject. The 
 pictures are especially good, particularly as they are practically all original and not the old 
 reproduced pictures so frequently seen." Published January, 1911 
 
 Davis' Accessory Sinuses 
 
 Development and Anatomy of the Nasal Accessory 
 Sinuses in Man. By Warren B. Davis, M. D., Corinna 
 Borden Keen Research Fellow of the Jefferson Medical College, 
 Philadelphia. Octavo of 172 pages, with 57 original illustra- 
 tions. Published March, 1914 Cloth, $3.50 llCt. 
 ORIGINAL DISSECTIONS 
 
 This book is based on the study of two hundred and ninety lateral nasal 
 walls, presenting the anatomy and physiology of the nasal accessory sinuses 
 from the sixtieth day of fetal life to advanced maturity. It was necessary for 
 Dr. Davis to develop a new iechnic by which the accessory sinus areas could 
 be removed en masse at the time of postmortem examinations, and still per- 
 mit of reconstruction of the face without marked disfigurement. 
 
GENITOURINARY AND NOSE, 77/R()A7\ Eu. g 
 
 Greene and Brooks' 
 Genito-Urinary Diseases 
 
 A Text=Book of Genito-Urinary Diseases. By Robert 
 H. Greene, M.D., Professor of Genito-Urinary Surgery at 
 Fordham University; and Harlow Brooks, M. D., Assistant Pro- 
 fessor of ClinicalMedicine, Universityand Bellevue Hospital Medi- 
 cal School. Octavo of 666 pages, illustrated. Cloth, $5.50 net. 
 
 FOURTH EDITION— published May. 1917 
 
 This new work covers completely the subject of genito-urinary diseases, 
 ]")resenting dotk the medical and surgical sides. Kidney diseases are very elabo- 
 rately detailed. 
 
 New York Medical Journal 
 
 " As a whole the book is one of the most satisfactory and useful works on genito- 
 urinary diseases now extant, and will undoubtedly be popular among practitioners and 
 students." 
 
 Gleason on Nose, Throat, 
 and Ear 
 
 A Manual of Diseases of the Nose, Throat, and Ear. By 
 
 E. Baldwin Glkason, M. D., LL. D., Professor of Otology, 
 Medico-Chirurgical College, Graduate School of Medicine, Uni- 
 versity of Pennsylvania, Philadelphia. 121110 of 590 pages, pro- 
 fusely illustrated. Cloth, ;^2. 75 net. Published October, 1914 
 
 THIRD EDITION 
 
 Methods of treatment have been simphfied as much as possible, so that in 
 most instances only those methods, drugs, and operations have been advised 
 which have proved essential. A feature consists of the collection of formulas. 
 
 American Journal of the Medical Sciences 
 
 " For the practitioner who wishes a reliable guide in laryngology and otology there ar 
 few books which can be more heartily commended." 
 
 Wilcox on Genito-Urinary and Venereal Dis- 
 eases Second Edition, published Jeoiuary. 1909 
 
 Essentials of Genito-Urtnary and Venereal Diseases. By 
 Starling S. Wilcox, M. D., Lecturer on Genito-Urinary Diseases and 
 Syphilologjr, Starling-Ohio Medical College, Columbus, Ohio. i2mo of 
 321 pages, illustrated. Cloth, $1.25 net. In Saunders Quesiwn-Com- 
 pends. 
 
SAUA'DEJ^S' BOOKS ON 
 
 Head's Modern Dentistry 
 
 Modern Dentistry. By Joseph Head, M. D., D.D.S., Den- 
 tist to the Jefferson Hospital, Philadelphia. Octavo of 374 
 pages, with 309 illustrations. Cloth, $5.00 net. 
 
 Published December, 1917 
 
 Dr. Head's book is a complete and up-to-date text-book on dentistry. 
 It gives you the principles upon which successful work must be based — 
 the technic in full, and the results of original experiments, with formulee, 
 instruments, and methods. It brings out clearly the \-arious factors which 
 influence the diagnosis, and carefully details the methods of treatment. 
 The subject of vaccines is gone into very fully, gi\ing }ou preparation and 
 use of autogenous, stock, and special vaccines. Particularly useful are 
 the sections on mouth hygiene, local anesthesia by novocain, electrolysis, 
 tooth discoloration, care of children's teeth and gums, orthodontia for 
 the general practitioner of dentistrj', cement, .v-ray stud\', and the use of 
 emetin. Over three hundred original illustrations show the student just 
 how the procedures are to be carried out. 
 
 Kyle's Nose and Throat 
 
 Diseases of the Nose and Tliroat. By D. Bradex Kvle, 
 M.D., formerly Professor of Laryngology in the Jefferson Medical 
 College, Philadelphia; Consulting Laryngologist, Rhinologist, 
 and Otologist, St. Agnes' Hospital. Octavo, 856 pages; with 
 272 illustrations and 27 lithographic plates in colors. Cloth, 
 
 tf , -Q net Published November, 1914 
 
 FIFTH EDITION 
 
 This work has now readied its fiftli edition. With the practical purpose 
 of the book in mind, extended consideration has been given to treatment, each 
 disease being considered in full, and definite courses being laid down to 
 meet special conditions and symptoms. 
 
 Pennsylvania Medical Journal 
 
 '■ l)r Kyle's crisp terse diction has enabled the inclusion of all needful nose and throat 
 knowledge in this book. The practical man, be he special or general, will not search in 
 vain for anything he needs." 
 
CHEMISTRY AXJ) DEXTrSTR Y 
 
 Holland's 
 Chemistry and Toxicology 
 
 A Text=Book of Medical Chemistry and Toxicology, 
 
 By Tames W. Holland, INI. D., Emeritus Professor of Medical 
 Chemistry and Toxicology , Jefferson Medical College, Phila- 
 delphia. Octavo, 678 pages, illustrated. Cloth, $3.00 net. 
 
 FOURTH EDITION— published April. 1915 
 
 Dr. Holland's work is an entirely new one, and is based on his tliir'y-five 
 vears' practical experience in teacliing chemistry and medicine. Recognizing 
 that to understand physiologic chemistry students must first be informed upon 
 points not referred to in most medical text-books, the author has included in his 
 work the latest views of equilibrium of equations, mass-action, cryoscopv, os- 
 motic pressure, etc. Much space is given to toxicology. 
 
 American Medicine 
 
 " Its statements are clear and terse ; its illustrations well chosen ; its development logi- 
 cal, systematic, and comparatively easy to follow. . . . We heartily commend the work." 
 
 Ivy's Applied Anatomy and Oral Surgery 
 
 Applied Anatomy and Oral Surgery for Dental Students. 
 By Robert H. Ivy, M. D., Li. D. S., Assistant Oral Surgeon to the 
 Philadelphia General Hospital. i2mo of 290 pages, illustrated. Cloth, 
 $1.75 net. Second Edition published July, 1917 
 
 This work is just what dental students have long wanted — a concise, practical work 
 on applied anatomy and oral surgery, written with their needs solely in mind. No 
 one could be better fitted for this task than Dr. Ivy, who is a graduate in both den- 
 tistry and mediciner The text is well illustrated with pictures that you will find e.x- 
 tremely helpful. 
 
 "I am delighted with this compact little treatise. It seems to me just to fill the 
 bill."— H. P. KuHN, M. D., lll-steru Dental College, Kansas City. 
 
 Oertel on Bright's Disease 
 
 The Anatomic Histological Processes of Bright's Disease. Bv 
 HoRST Oertel, M. D., Director of the Russell Sage Institute of Path- 
 ology, Xew York. Octavo of 227 pages, with 44 illustrations and 6 
 colored plates. Cloth, ;S5.oo net. 
 
 These lectures deal with the anatomic histological processes of Bright's disease, and 
 ■ in a somewhat different way from the usual manner. Everywhere relations are em- 
 phasized and an endeavor made to reconstruct the whole as a unit of interwoven 
 processes. PubUshed December, 1910 
 
 "Dr. Oertel gives a clear and intelligent idea of nephritis as a continuous process. 
 "We can strongly recommend this book as thoughtful, scientific, and suggestive."— 
 The Lancet, London. 
 
SAUXDEJ^S' BOOA'S ON 
 
 Goepp's Dental State Boards 
 
 Dental State Board Questions and Answers. By R. 
 
 Max Goepp, M. I)., Professor of Clinical Medicine at the Phila- 
 delphia Polyclinic. Octavo of 428 pages. Cloth, $3.00 net. 
 
 SECOND EDITION 
 
 Tliis new work is along the same practical lines as Dr. Goepp's successful 
 •work on Medical State Boards. The questions included have been gathered 
 from reliable sources, and embrace all those likely to be asked in any State 
 Board examination in any State. They have been arranged and classified in 
 a way that makes for a rapid resume of every branch of dental practice, -and 
 the answers are couched in language unusually explicit — concise, definite, 
 accurate. Published February, 1916 
 
 McConnell's Pathology and Bacteriology Dent&l 
 
 General Pathology and Bacteriology for Dental 
 Students. By Guthrie McConnell, M. D., .\ssistant 
 Surgeon, Medical Reserve Corps, U. S. N. 121110 of 314 
 
 pages, illustrated. Second Edition published January, 1918 
 
 This work was written expressly for dentists and dental students, em- 
 phasizing throughout the application of pathology and bacteriology in 
 dental study and practice. There are chapters on disorders of metab- 
 olism and circulation ; retrogressive processes, cell division, inflam- 
 mation and regeneration, granulomas, progressive processes, tumors, 
 special mouth pathology, sterilization and disinfection, bacteriologic 
 methods, specific micro-organisms, infection and immunity, and labora- 
 tory technic. 
 
EVE, EAR, NOSE, AND TIIROAr. 13 
 
 Bass and Johns* Alveolodental Pyorrhea 
 
 Alveolodental Pyorrhea. By Charles C. Bass, M.D., Professor 
 of Experimental Medicine, and Foster M. Johns, M. D., Instructor in 
 the Laboratories of Clinical Medicine, Tulane Medical College. Octavo 
 of 168 pages, illustrated. Cloth, $2.50 net. Published June, 1915 
 
 This work discusses alveolodental pyorrhea from the viewpoint of infection liy the 
 iEndamoeba buccalis in a simple, concise way, in the light of recent ijiformalion. 
 
 GleaSOn'S Nose and Throat Fourth Edition, Revised 
 
 Essentials of Diseases of the Nose and Throat. By E. B. 
 Gleason, S.B., M.D., Clinical Professor of Otology, Medico-Chirurgical 
 College, Graduate School of Medicine, University of Pennsylvania, 
 Post-octavo, 241 pages, 112 illustrations. Cloth, $1.25 net. In 
 Saunders' Question-Compend Series. Published October, 1914 
 
 "The careful description which is given of the various procedures would be sufficient 
 to enable most people of average intelligence and of slight anatomical knowledge to 
 make a very good attempt at laryngoscopy." — The Lancet, London. 
 
 Grant on the Face, Mouth, and Jaws 
 
 A Text-Book of the Surgical Principles and Surgical Dis- 
 eases OF the Face, Mouth, and Jaws. For Dental Students. By 
 H. Horace Grant, A. M., M. D., Professor of Surgery and of Clinical 
 Surgery, Hospital College of Medicine, Louisville. Octavo of 231 pages, 
 with 68 illustrations. Cloth, ^2.50 net. Published September, 1911 
 
 Preiswerk and Warren's Dentistry 
 
 Atlas and Epitome of Dentistry. By Prof. G. Preiswerk, of 
 Basil. Edited, with additions, by George W. Warren, D. D. S., Pro- 
 fessor of Operative Dentistry, Pennsylvania College of Dental Surgery, 
 Philadelphia. With 44 lithographic plates, 152 text-cuts, and 343 pages 
 of text. Cloth, ;^3.50 net. Saufuieii Hand- Atlases. August, 1906 
 
 Grunwald and Grayson on the Larynx 
 
 Atlas and Epitome of Diseases of the Larynx. By Dr. L. 
 GrOnwald, of Munich. Edited, with additions, by Charles P. 
 Grayson, M. D., University of Pennsylvania. With 107 colored figures 
 on 44 plates, 25 text-cuts, and 103 pages of text. Cloth, ^^2.50 net. In 
 Satinde7-s' Hand-Atlas Series. Published 1898 
 
 Mracek and Stelwagon's Atlas of Skin 
 
 Second 
 Edition 
 
 Atlas and Epitome of Diseases of the Skin. By Prof. Dr. 
 Franz Mracek, of Vienna. Edited, with additions, by Henry W\ 
 Stelw^agon, M. D., Jefferson Medical College. With 77 colored 
 plates, 50 half-tone illustrations, and 280 pages of text. Cloth, $4.00 
 net. /;/ Sautiders' Hand-Atlas Series. Published July, 1905 
 
t4 SAL'XJJEKS' /WOKS ON 
 
 Theobald's 
 Prevalent Diseases of the Eye 
 
 Prevalent Diseases of the Eye. By Samuel Theobald, 
 M. D., Clinical Professor of Ophthalmology and Otology, Johns 
 Hopkins University. Octavo of 550 pages, with 219 text-illustra- 
 tions and 10 plates. Cloth, $4.50 net. Published July, 1906 
 
 Chas. A. Oliver, M. D., 
 
 Clinical Professor of Of>hthaUnology, Wotnan's Medical College^ Phila. 
 " I feel I can conscientiously recommend it, not only to the general physician and 
 medical student, but also to the experienced ophthalmologist." 
 
 Wells' Chemical Pathology 
 
 Chemical Pathology. By H. Gideon Wells, Ph.D., 
 
 M. D., Professor of Pathology in the University of Chicago, 
 
 Octavo of 616 pages. Cloth, $3.25 net. Second Edition 
 
 Published March, 1914 
 Wm. H.Welch, lA.D., Johns Hopkins University. 
 
 " The work fills a real need in the English literature of a very important subject, and I 
 shall be glad to recommend it to my students." 
 
 Stel wagon's Essentials of Skin seventh Edition 
 
 Essentials of Diseases of the Skix. By Hexrv W. Stelw.-vgox, 
 M. D., Ph. D., Professor of Dermatology in the Jefferson Medical 
 College, Philadelphia. Post-octavo of 292 pages, with 72 text-illustra- 
 tions and 8 plates. Cloth, $1.25 net. In Saunders' Question-Corn pcnd 
 Series. Published August, 1909 
 
 "In line with our present knowledge of diseases of the skin. . . . Continues to main- 
 tain the high standard of excellence for which these question compends have been 
 noted." — The Medical News. 
 

 COLUMBIA UNIVERSITY LIBRARIES (hsi.stx) 
 
 RD 156 IV187 C.1 
 
 American addresses 
 
 2002106841 
 
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