Gilbertus Anglicus Part 6

s.p.a.ce does not permit a careful review of this interesting subject, but a novel form of poisoning by the use of quicksilver is startling enough to claim our attention. Gilbert tells us that pouring metallic mercury into the ear produces the most distressing symptoms, severe pain, delirium, convulsions, epilepsy, apoplexy and, if the metal penetrates to the brain, ultimate death. In the treatment of this condition certain physicians had recommended the insertion into the ear of a thin lamina of lead, upon which it was believed that the mercury would fasten itself and might thus be drawn out. Avicenna objected to this that the mercury was liable to speedily pa.s.s into the ear so deeply as to be beyond the reach of the lead. Gilbert suggests as an improvement of the treatment that a thin lamina of gold be subst.i.tuted for the lead, "because mercury thirsts after gold as animals do after water, as it is held in the books on alchemy" (_in libris allzinimicis_). This fact, too, he tells us can be easily demonstrated externally by placing upon a plate a portion of gold, and near, but not in contact with it, a little quicksilver, when the silver, he says, will at once "leap" upon the gold. Avicenna suggests that the patient stand upon the foot of the side affected, lean his head over to the same side, steady it in that position with the hands, and then leap suddenly over upon the other foot--demonstrating thereby his knowledge of both gravity and inertia. Manifestly our "laboratory physicians" of the present day can a.s.sume no airs of priority!

The Compendium closes with two very sensible chapters on the hygiene of travel, ent.i.tled "_De regimine iter agentium_" and "_De regimine transfretantium_."

In the hygiene of travel by land Gilbert commends a preliminary catharsis, frequent bathing, the avoidance of repletion of all kinds, an abundance of sleep and careful protection from the extremes of both heat and cold. The strange waters may be corrected by a dash of vinegar. Some travelers, he tells us, carry with them a package of their native soil, a few grains of which are added to the foreign waters, as a matter of precaution, before drinking. The breakfast of the traveler should be light, and a short period of rest after a day's travel should precede the hearty evening meal. Leavened bread two or three days old should be preferred. Of meats, the flesh of goats or swine, particularly the feet and neighboring parts, which, Gilbert tells us, the French call _gambones_, the flesh of domestic fowls and of the game fowls whose habitat is in dry places, is to be preferred to that of ducks and geese. Of fish, only those provided with scales should be eaten, and all forms of milk should be avoided, except whey, "which purifies the body of superfluities." Fruits are to be eschewed, except acid pomegranates, whose juice cools the stomach and relieves thirst. Boiled meats, seasoned with herbs like sage, parsley, mint, saffron, etc., are better than roasted meats, and onion and garlic are to be avoided.

The primitive conditions of land travel in the days of Gilbert are emphasized by his minute directions for the care of the feet, which he directs to be rubbed briskly with salt and vinegar and then anointed with an ointment of nettle-juice (_urtica_) and mutton-fat, or with a mixture of garlic, soap and oil. If badly swollen, they should be bathed, before inunction, with a decoction of elder-bark and other emollients.

In travel by sea, Gilbert tells us the four chief indications are to prevent nausea, to allay vomiting, to palliate the foul odor of the s.h.i.+p and to quiet thirst.

For the prevention of nausea he recommends the juice of acid pomegranates, lemons, etc., or a decoction of parsley or sweet cicely (_cerfolium_). The traveler should endeavor to sit with his head erect, should avoid looking around, but maintain his head as immovable as possible, and support himself by a firm grasp upon some beam of the s.h.i.+p. Some sweets may be sucked, or he may chew a few aromatic seeds.

If vomiting ensues, acid or sweet pomegranates, figs or barley-sugar (_penides_) may be taken sparingly, but no food should be ingested until the stomach is thoroughly quieted. Then the patient may take a little _stomatichon_ or _dyantos_, and a small portion of digestible food. As the diet must necessarily consist largely of salty food and vegetables, these should be cooked in three or four different waters, and then soaked in fresh water. A little aromatic wine will also benefit the patient, and a few aromatic seeds chewed in the morning are also of service.

The effect of the foul odors of the s.h.i.+p may be combatted by the use of aromatic electuaries, "which comfort the heart, the brain and the stomach." The patient should be removed to some quiet portion of the s.h.i.+p, as distant as possible from the channels for the discharge of the bilge-water, and short walks upon the upper deck will contribute to convalescence. Frequent changes of clothing will palliate the annoyance of fleas and pediculi. Drinking water may be purified by aeration, or by straining, boiling and subsequent sedimentation and removal of the sediment by filtration through fresh and clean sand.

For the wealthy, the water may be distilled in an alembic, if such an apparatus is obtainable. Avicenna says that bad water may be corrected by the addition of vinegar. Exposure to the midday sun and to the nocturnal cold, constipation and diarrhoea should be avoided, and prompt attention should be given to all disorders of the health.

To these wise counsels Gilbert courteously adds a medieval _bon voyage_ in these words:

"_Dominus autem omnia dirigat in tranquilitate. Amen._"

It has been already remarked upon a preceding page that Gilbert of England was not a surgeon. Nevertheless it is only fair to say that the surgical chapters of the Compendium present a more scientific and complete view of surgical art, as then known, than any contemporaneous writings of the Christian West, outside of Italy.

It is well known that during the Middle Ages the practice of surgery in western Europe was generally regarded as disreputable, and operative surgery was for the most part relegated to butchers, barbers, bath-keepers, executioners, itinerant herniotomists and oculists, _et id omne genus_, whose pernicious activity continued to make life precarious far down into the modern period.

In Italy alone did surgery vindicate for itself an equality with medicine, and the pioneer of this advance was Roger of Parma, who, as we have seen, flourished early in the thirteenth century. Roger and his pupil Roland, with the somewhat mythical "Four Masters" (_Quatuor Magistri_), were the surgical representatives of the School of Salernum, while Hugo (Borgognoni) di Lucca and his more famous son Theodorius represented the rival school of Bologna. Equally famous Italian surgeons of this century were Bruno of Logoburgo (in Calabria) and Gulielmus of Saliceto (1275), the master of Lanfranchi (1296).

Gilbert of England, as a pupil of Salernum, naturally followed the surgical teachings of that school, and we have already noticed that his chapters on surgery are taken chiefly from the writings of Roger of Parma, though the name of neither Roger, nor indeed of any other distinctly surgical writer, is mentioned in the Compendium. How closely in some cases Gilbert followed his masters may best be seen by a comparison of their respective chapters upon the same subject.

I accordingly introduce here for such comparison Roger's chapter on wounds of the neck, and the corresponding chapter of Gilbert. Roger says:

"_De vulnere quod fit in cervice._

"_Si vero c.u.m ense vel alio simili in cervice vulnus fiat, ita quod vena organica incidatur, sic est subveniendum. Vena tota sumatur (suatur) c.u.m acu, ita quod vena non perforetur, et ex alia parte acus c.u.m filo ei inhaerente ducatur, et c.u.m ipso filo nectatur atque stringatur, quod sanguinem non emittat: et ita facias ex superiori parte et inferiori. In vulnere autem pannus infusus mittatur, non tamen de ipso vulnus multum impleatur. Embrocha, si fuerit in myeme, superponatur quosque (quousque) vulnus faciat saniem. Si vero fuerit in aestate vitellus avi semper superponatur. Quum autem saniem fecerit, c.u.m panno sicco, unguento fusco et caeteris bonam carnem generantibus, adhibeatur cura, ut in caeteris vulneribus. Quum vero extremitatem venae superioris partis putruisse cognoveris, fila praedicta dissolvas, et a loco illo removeas: et deinde procedas ut dictum est superius. A. Si vero nervus incidatur in longum aut ex obliquo, sed non ex toto, hac cura potest consolidari. Terrestres enim vermes, idest qui sub terra nasc.u.n.tur, qui in longitudine et rotunditate lumbricis a.s.similantur, et apud quondam terrestres lumbrici dic.u.n.tur, accipiantur et aliquantulum conterantur et in oleo infusi ad ignem calefiant: et nullo alio mediante, ter vel quater, vel etiam pluries, si opportunum videbis, plagae impone. Si vero incidatur ex obliquo totus, minime consolidatur: praedicto tamen remedio non coadjuvante saepe conglutinatur. Potest etiam cuticula, quae supra nervum est, sui, pulvisque rubens, qui jam dictus est, superaspergi, quae cura non est inutilis, aliquos enim non solum conglutinatas, sed etiam consolidatas, nostra cura prospeximus. Si vero locus tumet, embrocham illam, quam in prima particula ad tumorem removendum, qui ex percussura contigit, praediximus, ponatur, quousque talis tumor recesserit._"

Gilbert, after premising two short chapters ent.i.tled "_De vulneribus colli_" and "_De perforatione colli ex utraque parte_," continues as follows:

"_De vena organica incisa._

"_Si vena organica in cervice incidatur: tota vena suatur c.u.m acu, ita quod vena non perforetur, et ux alia parte acus c.u.m filo ei adherente ita nectatur atque stringatur quod (non) emittat sanguinem, et ita fiat ex superiori parte et inferiore vene. In vulnere autem pannus infusus in alb.u.mine ovi mittatur, nec tamen de ipso panno vulnus multum impleatur. Embroca vero superius dicta, si in hyeme fuerit, superponatur, donec vulnus saniem emittat. Si vere in estate, vitellum ovi tum super ponatur, et c.u.m saniem fecerit, panno sicco, et unguento fusco et ceteris regenerantibus carnem, curetur. c.u.m vero extremitatem vene superioris et inferioris putruisse cognoveris, fila dissolvantur et a loco removeantur, et deinde ut dictum est procedatur._

"_De incisione nervi secundum longum aut secundum obliquum._

"_Si vero secundum longum aut obliquum vervi incidantur, et non ex toto, ita consolidamus. Terrestres vermes, qui sub terra nasc.u.n.tur, similes in longitudine et rotunditate lumbricis, qui etaim lumbrici terre appellantur: hi aliquantulum conterantur et in oleo infusi ad ignem calefiant, et nullo aliomediante, ter vel quater vel pluries, si opportunum fuerit, plagelle impone. Si vero ex oblique nervus incidatur, eodem remedio curatur, et natura cooperante saepe conglutinatur. Potest quoque cuticula quae supra nervum est sui, et pulvis ruber superaspergatur. Nervos enim conglutinari et consolidari hoc modo sepius videmus. Si vero locus tumeat, embroca, praedicta in vulnere capitis quae prima est ad tumorem removendum, superponatur, quousque tumor recesserit. Si vena organica non inciditur, pannus alb.u.mine ovi infusus in vulnere ponatur. Embroca vero post desuperponatur_" (f. 179 c).

The selection and collection of words and phrases in these two pa.s.sages leaves little doubt that one was copied from the other.

Indeed, so close is their resemblance that it is quite possible from the one text to secure the emendation of the other. Numerous similar pa.s.sages, with others in which the text of Gilbert is rather a paraphrase than a copy of the text of Roger, serve to confirm the conclusion that the surgical writings of the English physician are borrowed mainly from the "Chirurgia" of the Italian surgeon. Some few surgical chapters of the Compendium appear to be either original or borrowed from some other authority, but their number is not sufficient to disturb the conclusion at which we have already arrived. Now, as Roger's "Chirurgia" was probably committed to writing in the year 1230, when the surgeon was an old man, these facts lead us to the conclusion that Gilbert must have written his Compendium at least after the date mentioned.

Another criticism of these chapters suggests certain interesting chronological data. It will be observed that Roger, in the pa.s.sage quoted above, recommends a dressing of egg-alb.u.men for wounds of the neck, and expresses considerable doubt whether nerves, when totally divided, can be regenerated (_consolidari_), though they may undoubtedly be reunited (_conglutinari_).

Now Roland, in his edition of Roger's "Chirurgia," criticises both of these statements of his master, as follows:

_Nota quod quamvis Rogerius dicat quod apponatur alb.u.men ovi, non approbo, quia frigidum est naturaliter, et vena et nervus et arteria frigida sunt naturaliter, et propter frigiditatem utrorumque non potest perfecte fieri consolidatio._

And again:

_Nota quod secundum Rogerium nervus omnino incisus non potest consolidari, vel conjungi nec sui. Nos autem dicimus quod potest consolidari et iterum ad motum reddi habillis, c.u.m hac cautela: Cauterizetur utrumque caput nervi incisi peroptime c.u.m ferro candenti, sed cave vulneris lobia c.u.m ferro calido tangantur. Deinde apponantur vermes contusi et pulveres consolidativi, etc._

It will be observed that Gilbert, in spite of the rejection by Roland of the egg-alb.u.men dressing of Roger, still recommends its use in wounds of the neck, and although he professes to have seen many nerves regenerated (_consolidari_) under the simple angle-worm treatment of his master, he still makes no mention of the painful treatment of divided nerves by the actual cautery, so highly praised by Roland. It would seem, therefore, that Gilbert was not familiar with the writings of Roland when his Compendium was written, or he would, doubtless, not have omitted so peculiar a plan of treatment in an injury of such gravity. As Roland's edition of Roger's "Chirurgia" is said to have been written in 1264, the comparison of these pa.s.sages would seem to indicate that Gilbert must have written the Compendium after 1230 and prior to the year 1264.

Gilbert's surgical chapters discuss the general treatment of wounds and their complications, and more specifically that of wounds of the head, neck, throat, wounds of nerves, of the oesophagus, scapula, clavicle, of the arm, the stomach, intestines and the spleen; fractures of the clavicle, arm, forearm and ribs; compound fractures; dislocations of the atlas, jaw, shoulder and elbows; fistulae in various localities, and the operations on the tonsils and uvula, on goitre, hernia and stone in the bladder, etc.--certainly a surgical compendium of no despicable comprehensiveness for a physician of his age and country.

In the general treatment of wounds (f. 86 c) Gilbert tells us the surgeon must consider the time, the age of the patient, his temperament (_complexio_) and the locality, and be prepared to temper the hot with the cold and the dry with the moist. Measures for healing, cleansing and consolidation are required in all wounds, and these objects may, not infrequently, be accomplished by a single agent. The general dressing of most wounds is a piece of linen moistened with the white of egg (_pecia panni in alb.u.mine ovi infusa_), and, as a rule, the primary dressing should not be changed for two days in summer, and for three days in the winter. In moist wounds _vitreolum_ reduces the flesh; in dry wounds it repairs and consolidates. _Flos aeris_, in dry wounds, reduces but does not consolidate, but rather corrodes the tissues. Excessive suppuration is sometimes the result of too stimulating applications, sometimes of those which are too weak. In the former case the wound enlarges, a.s.sumes a concave form, is red, hot, hard and painful, and the pus is thin and watery (_subtilis_). If the application is too weak, the pus is thick and viscous, and the other signs mentioned are wanting. In either case the dressings are to be reversed. If any dyscrasia, such as excessive heat, coldness, dryness or moisture appears in the wound and delays its healing, it is to be met by its contrary. If fistula or cancer develops, this complication is to be first cured and then the primary wound. The signs of a hot dyscrasia are heat, burning and pain in the wound; of a cold dyscrasia, lividity of the wound; the moist dyscrasia occasions flabbiness (_mollicies_) and profuse suppuration, and the dry produces dryness and induration.

Wounds of the head (f. 84 c) occur with or without fracture of the cranium, but always require careful examination and exact diagnosis.

The wound is to be carefully explored with the finger, and, if necessary, should be enlarged for this purpose. Large, but simple, wounds of the scalp should be st.i.tched with silk in three or four places, leaving the most dependent angle open for escape of the discharges, and in this opening should be inserted a tent (_tuellus_), to facilitate drainage. The wound is then sprinkled with the _pulvis rubeus_ and covered with a plantain or other leaf. On the ninth to the eleventh day, if the wound seems practically healed, the st.i.tches are to be removed and the cure completed with simple dressings.

The signs and symptoms of fracture of the cranium are: Loss of appet.i.te and failure of digestion, insomnia, difficulty in micturition, constipation, a febrile dyscrasia, difficulty in cracking nuts or crusts of bread with the jaws, or severe pain when a string is attached to the teeth and pulled sharply. If the meninges are injured we have further: headache, a slow and irregular but increasing fever, alternating with chills, distortion of the angles of the eyes, redness of the cheeks, mental disturbances, dimness of vision, a weak voice and bleeding from the ears or the nose. In the presence of such symptoms the death of the patient may be expected within at most a hundred days.

If the fracture of the cranium is accompanied by a large scalp wound, any fragments of bone or other foreign body are to be extracted at once, unless haemorrhage or the weakness of the patient are feared, and then a piece of linen is to be cautiously worked in with a feather between the cranium and the dura mater. In the fracture itself a piece of linen, or better of silk, is inserted, the apparent purpose of this double dressing being to protect the dura mater from the discharges and to solicit their flow to the exterior. A piece of sponge, carefully washed, dried and placed in the wound, Gilbert tells us, absorbs the discharges satisfactorily and prevents their penetration internally. Over the wound is placed a bit of linen moistened with egg-alb.u.men, then a dressing of lint, and the whole is maintained in place by a suitable bandage. Finally the patient is to be laid in bed and maintained in such a position that the wound will be dependent, so as to favor the ready escape of the discharges. This dressing is to be renewed three times a day in summer, and twice in winter. Proud flesh upon the dura mater is to be repressed by the application of a sponge, well-washed and dried, and if it appears upon the surface of the wound after the healing of the fracture, it is to be destroyed by the use of the hermodactyl. When the external wound is healed, the cicatrix is to be dressed with the _apostolicon cyrurgic.u.m_, an ointment very valuable for the consolidation of bones, the leveling (_adaequatio?_) of wounds, etc.

When the wound of the scalp is small, so as to render difficult the determination of the extent of the fracture by exploration with the finger, it should be enlarged by crucial incisions, the flaps loosened from the cranium by a suitable sc.r.a.per (_rugine_) and folded back out of the way, and any fragments of bone removed by the forceps (_pinceolis_). If, however, haemorrhage prevents the immediate removal of the fragments, this interference may be deferred for a day or two, until the bleeding has stopped or has been checked by suitable remedies. Then, after their removal, the piece of linen described above is to be inserted between the cranium and dura mater. Upon the cranium and over the flaps of the scalp, as well as in their angles, the ordinary dressing of alb.u.men is to be applied, covered by a pledget of lint and a suitable bandage. No ointment, nor anything greasy, should be applied until after the healing of the wound, lest some of it may accidentally run down into the fracture and irritate the dura matter. Some surgeons, Gilbert tells us, insert in the place of the fragments of the cranium removed a piece of a cup (_ciphi_) or bowl (_mazer_), or a plate of gold, but this plan, he says, has been generally abandoned (_dimitt.i.tur_.)

Sometimes the cranium is simply cracked without any depression of the bone, and such fractures are not easily detected. Gilbert tells us, however, that if the patient will close firmly his mouth and nose and blow hard, the escape of air through the fissured bone will reveal the presence of the fracture (f. 88a). In the treatment of such fissures he directs that the scalp wound be enlarged, the cranium perforated very cautiously with a trepan (_trepano_) at each extremity of the fissure and the two openings then connected by a chisel (_spata_?), in order to enable the surgeon to remove the discharges by a delicate bit of silk or linen introduced with a feather. If a portion of the cranium is depressed so that it cannot be easily raised into position, suitable openings are to be made through the depressed bone in order to facilitate the free escape of the discharges.

Gunshot wounds were, of course, unknown in Gilbert's day. In a chapter ent.i.tled "_De craneo perforato_" he gives us, however, the treatment of wounds of the head produced by the transfixion of that member by an arrow. If the arrow pa.s.ses entirely through the head, and the results are not immediately fatal, he directs the surgeon to enlarge the wound of exit with a trephine, remove the arrowhead through this opening, and withdraw the shaft of the arrow through the wound of entrance. The wounds of the cranium are then to be treated like ordinary fractures of that organ (f. 88c).

In wounds of the neck involving the jugular vein (_vena organica_), Gilbert directs ligation of both extremities of the wounded vessel, after which the wound is to be dressed (but not packed) with the ordinary dressing of egg-alb.u.men.

Wounds of nerves are treated with a novel dressing of earthworms lightly beaten in a mortar and mixed with warm oil, and he professes to have seen nerves not only healed (_conglutinari_), but even the divided nerve fibres regenerated (_consolidari_) under this treatment.

In puncture of a nerve Gilbert surprises us (f. 179d) by the advice to divide completely the wounded nerve, in order to relieve pain and prevent teta.n.u.s (_spasmus_).

Goitre, not too vascular in character, is removed by a longitudinal incision over the tumor, after which the gland is to be dragged out, with its entire capsule, by means of a blunt hook. A large goitre in a feeble patient, however, is better left alone, as it is difficult to remove all the intricate roots of the tumor, and if any portion is left it is p.r.o.ne to return. In such cases Gilbert says we shrink from the application of the actual cautery, for fear of injury to the surrounding vessels and nerves. Whatever method of operation is selected, the patient is to be tied to a table and firmly held in position.

Wounds of the trachea and oesophagus, according to Gilbert, are invariably mortal.

In wounds of the thorax the ordinary dressing of alb.u.men is to be applied, but if blood or pus enters the cavity of the thorax, the patient is directed to bend his body over a dish, twisting himself from one side to another (_supra disc.u.m[10] flectat se modo hac modo ilac vergendo_) until he expels the sanies through the wound, and to always lie with the wound dependent until it is completely healed (f.

182d).

[Footnote 10: It is interesting to observe how the Latin discus developed dichotomously into the English "dish" and the German "Tisch." The former is doubtless the meaning of the word in this place.]

In case an arrow is lodged within the cavity of the thorax, the surgeon is directed to trepan the sternum (_os pectoris_), remove the head of the arrow gently from the shaft, and withdraw the shaft itself through the original wound of entrance. If the head is lodged beneath or between the ribs, an opening is to be made into the nearest intercostal s.p.a.ce, the ribs forced apart by a suitable wedge and the head thus extracted. The wound through the soft parts is to be kept open by a tent greased with lard and provided with a suitable prolongation (_cauda aliqua_) to facilitate its extraction and prevent its falling into the cavity of the chest.

Wounds of the heart, lungs, liver, stomach and diaphragm are regarded as hopelessly mortal (f. 233d), and the physician is advised to have nothing to do with them. Wounds of the heart are recognized by the profuse haemorrhage and the black color of the blood; those of the lung by the foamy character of the blood and the dyspnoea; wounds of the diaphragm occasion similar dyspnoea and are speedily fatal; those of the liver are known by the disturbance of the hepatic functions, and wounds of the stomach by the escape of its contents. Wounds of the intestine are either incurable, or at least are cured only with the utmost difficulty. Longitudinal wounds of the spine which do not penetrate the cord may be repaired, but transverse wounds involving the cord, so that the latter escapes from the wound, are rarely, if ever, cured by surgery. Wounds of the kidneys are also beyond the art of the surgeon. Wounds of the p.e.n.i.s are curable, and if the wound is transverse and divides the nerve, they are likewise painless.

_Si vene t.i.tillares in c.o.xis abscidantur h.o.m.o moritur ridendo._ A pa.s.sage which I can refer only to the erudition and risibility of our modern surgeons and anatomists. The ticklish _vene t.i.tillares_ are to me entirely unknown.

Modern abdominal surgeons will probably be interested in reading Gilbert's chapter on the treatment of wounds of the intestines in the thirteenth century. He says (f. 234c):

If some portion of the intestine has escaped from a wound of the abdomen and is cut either longitudinally or transversely, while the major portion remains uninjured; if the wound has existed for some time and the exposed intestine is cold, some living animal, like a puppy (_catulus_), is to be killed, split longitudinally and placed over the intestine, until the latter is warmed, vivified by the natural heat and softened. Then a small tube of alder is prepared, an inch longer than the wound of the intestine, carefully thinned down (_subtilietur_) and introduced into the gut through the wound and st.i.tched in position with a very fine square-pointed needle, threaded with silk. This tube or canula should be so placed as to readily transmit the contents of the intestine, and yet form no impediment to the st.i.tches of the wound. When this has been done, a sponge moistened in warm water and well washed should be employed to gently cleanse the intestines from all foreign matters, and the gut, thus cleansed, is to be returned to the abdominal cavity through the wound of the abdominal wall. The patient is then to be laid upon a table and gently shaken, in order that the intestines may resume their normal position in the abdomen. If necessary the primary wound should be enlarged for this purpose. When the intestines have been thus replaced, the wound in the abdominal wall is to be kept open until the wound of the intestine seems healed. Over the intestinal suture a little _pulvis ruber_ should be sprinkled every day, and when the wound of the intestine is entirely healed (_consolidatur_), the wound of the abdominal wall is to be sewed up and treated in the manner of ordinary flesh wounds.

If, however, the wound is large, a pledget (_pecia_) of lint, long enough to extend from one end to the other and project a little, is placed in the wound, and over this the exterior portion of the wound is to be carefully sewed, and sprinkled daily with the _pulvis ruber_.

Every day the pledget which remains in the wound is to be drawn towards the most dependent part, so that the dressing in the wound may be daily renewed. When the intestinal wound is found to be healed, the entire pledget is to be removed and the unhealed openings dressed as in other simple wounds. The diet of the patient should be also of the most digestible sort.