be disturbed, the attempts to remove it had perhaps better be desisted from. But even in such instances the very fact of a foreign body being known to be in a hazardous or objectionable situation is all the more reason for its removal from it; and it really becomes rather a question regarding the anatomical knowledge and operative skill of the surgeon, than of the propriety of the extraction of the foreign body. Again, a bullet may be lying in such a situation that from its depth, or from the tortuous course it has taken, it cannot be extracted by the opening of entrance, while either the time or circumstances may render it unadvisable to undertake a cutting operation for its removal. These, however, are exceptional occurrences, which must be taken into account when the particular cases concerned fall under the notice of surgeons; they do not destroy the propriety of the general rule for the immediate extraction of lodged foreign bodies when wounds with such complications are first brought to the notice of surgeons at field hospitals.

Instances will occasionally occur in which a surgeon will meet with reiterated failures in his attempts to extract a foreign body, notwithstanding that the site of its lodgment is known. If the fatigue and pain of the operation threaten to exhaust the patient's power of endurance, or the repeated attempts at extraction are causing injury to the parts concerned in the track of the projectile, common prudence dictates that the efforts should be desisted from. No rule can be given as to the precise period when attempts at extraction should be stopped in such instances. The time will vary with the particular features of each case, and also with the operative skill and dexterity of the surgeon. A wise surgeon will of his own accord see when the time has come at which due consideration of the circumstances before him compels him to stop further attempts at extraction.

Manipulation for extraction of foreign bodies. If the foreign body should happen to be lying within reach by the wound of entrance, it should be extracted direct through this opening by an appropriate instrument. An ordinary dressing forceps will suffice for extracting it when it is near the opening, or the forefinger of the surgeon, either alone or with the aid of a steel director, will equally answer the purpose. If the situation of the foreign body be deep, but not so deep as to be felt on the opposite side of the limb or part where it effected its entrance, the extraction should be made by some one of the regular bullet-extractors described farther on, and the operation conducted with more caution and skill, as the finger cannot in such a case be employed as a guide.

The operation of extracting a missile which is lodged among muscular tissues a short distance from the surface is an easy matter enough. But when lodged deeply it often requires more adroitness and patience than a theoretical consideration of the

matter would lead a surgeon to anticipate. The ease with which a hard and smooth projectile eludes the attempts made to grasp it, and slips aside into the soft tissues among which it is lying; the frequency with which some of these mobile tissues get before the instrument and impede the prehension of the missile itself; the liability of bullets, after they have become deformed, as well as of all foreign bodies of jagged and irregular outlines, to be caught and held firmly by some of the surrounding tissues;-these are common sources of difficulty in the way of extracting lodged projectiles. Moreover, a recollection of the sinuous and irregular directions of the tracks which are often left by missiles through parts of the body; of the varied forms and dimensions of the openings left by them in different anatomical structures, especially the slit-like openings frequently met with in fascial and muscular aponeuroses; of the ease with which parts of the soft tissues may be pushed in front of an unyielding instrument; together with the tendency of the perforated structures to alter their relative positions before inflammatory adhesions have occurred among them-will further explain some of the impediments which are often encountered even in early attempts to grasp deeply lodged foreign bodies, or to withdraw them from their places of lodgment after they have been grasped. When foreign bodies have been lodged for lengthened periods, other obstacles arise in the way of their extraction; but these are not met with in recent wounds.

Most English surgeons have hitherto used for extracting such relatively small projectiles as rifle and pistol bullets a twobladed forceps, or the instrument known in England as 'Coxeter's bullet-extractor,' and have followed the rule of removing them by the shortest and surest channel. The forceps has been most generally employed for the purpose, though Coxeter's extractor has the advantage of distending the track less, as will be explained in the description of the instrument. Whichever be used, it will generally be found necessary to enlarge the entrance opening of one of these small projectiles by incision, if this has not been already done for facilitating the exploration of the wound. The opening in the fascia will particularly require to be dilated. If the track of the bullet be very narrow, as it will always be in a flesh wound by one of the present small-bore rifle bullets, it may be essential to incise some parts of it also; but this can only be a most exceptional occurrence, since such missiles can scarcely ever remain lodged, as before mentioned, owing to their enormous penetrative power. The finger, when the track is free enough, should be inserted alone, and the position of the bullet thoroughly recognised; and while the end of the finger remains in contact with it, the instrument should be passed along the wound by the side of the finger, which will then act as a guide. The blades of the forceps should now be opened, and the bullet fixed between

them, the finger-nail being used for the purpose of pushing aside any soft tissue that might otherwise be caught between either blade and the bullet. The same manoeuvre should be performed by the end of the finger in gradually clearing the way for the scoop of Coxeter's extractor to get behind the bullet, and for afterwards fixing it in position by the points of the stem of the instrument. Deliberate effort should be made to get a firm hold of the missile before any further proceeding is attempted. As soon as the bullet is felt to be well secured by either instrument, the finger is slowly withdrawn, and then by careful and steady manipulation to prevent the bullet, especially if it be altered in shape, from being caught by some of the tissues through which the instrument holding it has to pass, or from catching others of importance, which may be lying by the side of the track, the foreign body should be gradually extracted. In a wound in which there is not space enough to admit both the finger and the extractor, the instrument can only be inserted after the finger is withdrawn; but the operation is seldom so quickly or so satisfactorily performed as it is when the finger can be employed as a guide to the passage of the instrument, and as a means of determining that the missile alone is grasped by it. When a forceps is employed, there is always the liability of some of the soft tissues being included in the triangular space bounded by the two arms of the forceps and the projectile which is grasped by its blades, and if so included, it is not possible to extract the projectile without the tissue being torn asunder. When the forefinger is within the wound in addition to the forceps, this occurrence can readily be prevented, and the blades cleared from all beside the foreign body to be removed.

In any case when the insertion of the finger has not been admissible, and the character of the resistance offered to the withdrawal of the projectile is such as to lead to a suspicion that something else has been grasped with it, the attempt to draw out the instrument should not be continued. The blades of the forceps should rather be opened, the bullet set free, and another grasp made; or the instrument should be withdrawn altogether, and a fresh exploration made by the finger with a view to clearing away any tissue that may be lying across the projectile.

Especial care should be taken not to extract a soft foreign body such as a piece of cloth, leather, or linen, from a deep situation roughly or with haste, lest by accident some of the natural soft tissues may have been seized instead of it, or with it. When using traction, notice should be taken whether pain is caused as the traction is made, and whether the substance grasped resists quitting its place of lodgment. In the latter case the operation of extraction should be stopped, and a fresh exploration be made before it is resumed.

One not uncommon impediment in the way of the extraction of leaden missiles when they have become distorted in form, and of all hard irregularly-shaped foreign bodies, is the entanglement or actual interlinking of fibres of cellular and other tissues with the small rugged inequalities of their surfaces and edges. They sometimes seem to act as barbed hooks would, and hold the fibres so tightly that they cannot be disentangled by simple change of position, but must be divided before the separation can be effected. Should an armoured rifle bullet of the present day happen to lodge while retaining its normal form, it would be free from any such hindrance to its removal; but if it had struck a hard substance before entering, so that its metallic cover had been more or less detached from the core, the opposition to its extraction would be especially difficult to overcome. If the finger can reach the projectile, the entangling fibres may often be detached or scraped across by the finger-nail; but if the missile is within convenient reach for the purpose, it is a simpler proceeding to divide them by the edge of a knife.

In the days when spherical bullets were the foreign bodies which had chiefly to be removed from wounds, no attention was necessary as to the direction in which the projectile was to be withdrawn; so long as a hold of it was secured, there was little else to be considered. But with an elongated projectile unaltered in shape, it becomes important that the removal should be effected with its long axis in line with the course of the wound. To grasp a bullet upwards of an inch in length in the contrary direction could only be done by an unjustifiable separation of the blades of the forceps, and stretching of the walls of the contused track forming the wound. If the instrument be one of Coxeter's bullet-extractors, care should be taken that the long axis of the projectile corresponds with the long axis of the scoop. The same care should be exercised by the surgeon in withdrawing slugs, fragments of shell, stones, and all other such unyielding and irregularly-shaped bodies from the bottom of wounds; the walls of which, it is to be remembered, are in a condition highly susceptible to further injury, owing to the severe contusion to which they have previously been subjected.

If the projectile be impacted in bone, in some of the bones of the foot, or in any situation where the fact of the lodgment can be fully established, the depth to which it has sunk into the substance of the bone should be noted, and the means for removing it determined according to its state in this respect. If it be only sticking in a bone superficially placed, after exposing it to view by suitable incisions, it can be readily detached by an elevator. If it be deeply sunk, the elevator cannot be brought to bear suitably upon it, and none of the ordinary bullet-extractors will be of much avail. If a tirefond screw be available, it will suffice to effect the desired extraction; but if this instrument cannot be obtained, some thin

layers of the contused bone immediately surrounding the projectile should be gouged away, so that less opposition may be offered by the surrounding bone to its escape. An elevator or common dressing forceps will then generally accomplish the removal. In other cases, as when projectiles are firmly fixed in the shafts of bones, or have sunk to some depth in thin spongy extremities, the only means of removing them will be by the same operative proceedings which a surgeon would have to adopt for the removal of a necrosed sequestrum similarly placed. Such cases, however, will probably be exceedingly rare in the future so far as rifle projectiles are concerned.

Removal of foreign bodies by incision.-In the cases above considered the object has been supposed to be to effect the extraction of the foreign body by the path along which it travelled to its resting-place. But if the lodged bullet or other foreign body cannot be reached by the wound of entrance, but can be felt lodged in the flesh at some part distant from it; or if any circumstances exist contra-indicating its direct extraction, such as its having reached a site beneath structures which there would be risk of injuring, or which would have to be extensively divided in order that the foreign body might be laid hold of; or if, having just stopped short of completely perforating a limb, it is felt lying beneath the skin, or not far from the surface at some point opposite to, or at a distance away from, that where it entered;-in all these and similar cases an incision should be made for its extraction after taking the usual steps to ensure perfect cleanliness of everything employed in the operation. Such counter-openings often have the additional advantage of assisting the cure of the wound by facilitating the escape from it of sloughs and purulent secretions.

The extraction of a lodged bullet by incision may also be advantageous for other reasons. A bullet may be fairly and firmly in the grasp of an extricating instrument, but it may be found that an unjustifiable amount of force would have to be used for effecting its withdrawal. It may be lying so far from the opening through which the instrument has been passed that the finger may not be able to reach it, and the nature of the impediment to its extraction may be unknown, or, at best, only a matter of surmise. When such a difficulty arises, the surgeon will act wisely in not trying to overcome it by excessive force. After various movements have been resorted to with a view to disengaging it from the obstacles which are barring the way to its removal, and have failed, an incision, for reaching the missile by a more direct route, if it be in a favourable position for such means of access, will be a more prudent course to adopt. The following example affords a lesson on the importance of this injunction; for owing to the changed form of the bullet and the situation in which it had become placed,