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Library of Congress Cataloging-in-Publication Data
Introduction to biomedical engineering / [edited by] John Enderle, Joseph Bronzino. – 3rd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-12-374979-6 (alk. paper)
1. Biomedical engineering. I. Enderle, John D. (John Denis) II. Bronzino, Joseph D., 1937-
[DNLM: 1. Biomedical Engineering. QT 36]
R856.I47 2012
610.28–dc22 2010046267
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library.
For information on all Academic Press publications
visit our Web site at www.elsevierdirect.com
Printed in the United State of America
11 12 13 14 9 8 7 6 5 4 3 2 1](https://image.slidesharecdn.com/30090-250530060028-9b383353/85/Introduction-to-biomedical-engineering-3ed-Edition-Enderle-J-10-320.jpg)
![As soon as the smoke had risen the smart rattle of our volley rang
out. Three times I gave the same commands, and each detonation
seemed an echo to the one from the rifles of our comrades. Then
there was a pause.
The enemy's fire had slackened considerably, and the noise of the
projectiles as they struck the wall and roof of the pagoda, sang
overhead or clattered through the branches of the banyan, was
hardly noticeable when compared to the racket they had kept up a
few minutes before. From the hillocks before us only occasional puffs
of smoke arose, followed by isolated reports from their rifles.
At his call I went out to our "non-com," who said:
"They seem to be sick of it, and certainly show no disposition to rush
us. I wish they would try, Sacré bleu! The ground is too open for
them. If we could depend on the linhs—but we can't—we might
make a dash for the convoy; without them the odds are too great,
so I have decided to withdraw. I will start off with this lot. When we
have got away give them a volley to keep them still; and if they
show any signs of moving, a little independent firing. Don't be
extravagant, though. You understand?"
PAGODA USED FOR AMBUSH.
[See page 139.]
"Yes," I answered. "But you must take that wounded linh; he would
hamper me."](https://image.slidesharecdn.com/30090-250530060028-9b383353/85/Introduction-to-biomedical-engineering-3ed-Edition-Enderle-J-36-320.jpg)
Introduction to biomedical engineering 3ed. Edition Enderle J.
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- 5. Introduction to biomedical engineering 3ed. Edition Enderle J. Digital Instant Download Author(s): Enderle J., Bronzino J. ISBN(s): 9780123749796, 0123749794 Edition: 3ed. File Details: PDF, 15.47 MB Year: 2011 Language: english
- 7. INTRODUCTION TO BIOMEDICAL ENGINEERING THIRD EDITION
- 8. This is a volume in the ACADEMIC PRESS SERIES IN BIOMEDICAL ENGINEERING JOSEPH BRONZINO, SERIES EDITOR Trinity College—Hartford, Connecticut
- 9. INTRODUCTION TO BIOMEDICAL ENGINEERING THIRD EDITION JOHN D. ENDERLE University of Connecticut Storrs, Connecticut JOSEPH D. BRONZINO Trinity College Hartford, Connecticut
- 10. Academic Press is an imprint of Elsevier 30 Corporate Drive, Suite 400, Burlington, MA 01803, USA The Boulevard, Langford Lane, Kidlington, Oxford, OX5 1GB, UK # 2012 Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. MATLABW and SimulinkW are trademarks of The MathWorks, Inc. and are used with permission. The MathWorks does not warrant the accuracy of the text or exercises in this book. This book’s use or discussion of MATLABW and SimulinkW software or related products does not constitute endorsement or sponsorship by The MathWorks of a particular pedagogical approach or particular use of the MATLABW and SimulinkW software. Library of Congress Cataloging-in-Publication Data Introduction to biomedical engineering / [edited by] John Enderle, Joseph Bronzino. – 3rd ed. p. ; cm. Includes bibliographical references and index. ISBN 978-0-12-374979-6 (alk. paper) 1. Biomedical engineering. I. Enderle, John D. (John Denis) II. Bronzino, Joseph D., 1937- [DNLM: 1. Biomedical Engineering. QT 36] R856.I47 2012 610.28–dc22 2010046267 British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library. For information on all Academic Press publications visit our Web site at www.elsevierdirect.com Printed in the United State of America 11 12 13 14 9 8 7 6 5 4 3 2 1
- 11. This book is dedicated to our families.
- 12. This page intentionally left blank
- 13. Contents Preface xi Contributors to the Third Edition xiii Contributors to the Second Edition xiv Contributors to the First Edition xv 1. Biomedical Engineering: A Historical Perspective JOSEPH D. BRONZINO 1.1 The Evolution of the Modern Health Care System 2 1.2 The Modern Health Care System 9 1.3 What Is Biomedical Engineering? 16 1.4 Roles Played by the Biomedical Engineers 21 1.5 Recent Advances in Biomedical Engineering 23 1.6 Professional Status of Biomedical Engineering 29 1.7 Professional Societies 30 1.8 Exercises 32 2. Moral and Ethical Issues JOSEPH D. BRONZINO 2.1 Morality and Ethics: A Definition of Terms 36 2.2 Two Moral Norms: Beneficence and Nonmaleficence 44 2.3 Redefining Death 45 2.4 The Terminally Ill Patient and Euthanasia 49 2.5 Taking Control 52 2.6 Human Experimentation 53 2.7 Definition and Purpose of Experimentation 55 2.8 Informed Consent 57 2.9 Regulation of Medical Device Innovation 62 2.10 Marketing Medical Devices 64 2.11 Ethical Issues in Feasibility Studies 65 2.12 Ethical Issues in Emergency Use 67 2.13 Ethical Issues in Treatment Use 70 2.14 The Role of the Biomedical Engineer in the FDA Process 71 2.15 Exercises 72 3. Anatomy and Physiology SUSAN BLANCHARD AND JOSEPH D. BRONZINO 3.1 Introduction 76 3.2 Cellular Organization 78 3.3 Tissues 93 3.4 Major Organ Systems 94 3.5 Homeostasis 126 3.6 Exercises 129 4. Biomechanics JOSEPH L. PALLADINO AND ROY B. DAVIS III 4.1 Introduction 134 4.2 Basic Mechanics 137 4.3 Mechanics of Materials 158 4.4 Viscoelastic Properties 166 4.5 Cartilage, Ligament, Tendon, and Muscle 170 4.6 Clinical Gait Analysis 175 4.7 Cardiovascular Dynamics 192 4.8 Exercises 215 5. Biomaterials LIISA T. KUHN 5.1 Materials in Medicine: From Prosthetics to Regeneration 220 5.2 Biomaterials: Types, Properties, and Their Applications 221 5.3 Lessons from Nature on Biomaterial Design and Selection 236 5.4 Tissue–Biomaterial Interactions 240 5.5 Biomaterials Processing Techniques for Guiding Tissue Repair and Regeneration 250 vii
- 14. 5.6 Safety Testing and Regulation of Biomaterials 258 5.7 Application-Specific Strategies for the Design and Selection of Biomaterials 263 5.8 Exercises 269 6. Tissue Engineering RANDALL E. MCCLELLAND, ROBERT DENNIS, LOLA M. REID, JAN P. STEGEMANN, BERNARD PALSSON, AND JEFFREY M. MACDONALD 6.1 What Is Tissue Engineering? 274 6.2 Biological Considerations 290 6.3 Physical Considerations 319 6.4 Scaling Up 339 6.5 Implementation of Tissue Engineered Products 343 6.6 Future Directions: Functional Tissue Engineering and the “-Omics” Sciences 347 6.7 Conclusions 349 6.8 Exercises 349 7. Compartmental Modeling JOHN D. ENDERLE 7.1 Introduction 360 7.2 Solutes, Compartments, and Volumes 360 7.3 Transfer of Substances between Two Compartments Separated by a Membrane 362 7.4 Compartmental Modeling Basics 379 7.5 One-Compartment Modeling 381 7.6 Two-Compartment Modeling 391 7.7 Three-Compartment Modeling 403 7.8 Multicompartment Modeling 418 7.9 Exercises 430 8. Biochemical Reactions and Enzyme Kinetics JOHN D. ENDERLE 8.1 Chemical Reactions 448 8.2 Enzyme Kinetics 458 8.3 Additional Models Using the Quasi-Steady-State Approximation 467 8.4 Diffusion, Biochemical Reactions, and Enzyme Kinetics 473 8.5 Cellular Respiration: Glucose Metabolism and the Creation of ATP 485 8.6 Enzyme Inhibition, Allosteric Modifiers, and Cooperative Reactions 497 8.7 Exercises 505 9. Bioinstrumentation JOHN D. ENDERLE 9.1 Introduction 510 9.2 Basic Bioinstrumentation System 512 9.3 Charge, Current, Voltage, Power, and Energy 514 9.4 Resistance 520 9.5 Linear Network Analysis 531 9.6 Linearity and Superposition 537 9.7 Thévenin’s Theorem 541 9.8 Inductors 544 9.9 Capacitors 548 9.10 A General Approach to Solving Circuits Involving Resistors, Capacitors, and Inductors 551 9.11 Operational Amplifiers 560 9.12 Time-Varying Signals 572 9.13 Active Analog Filters 578 9.14 Bioinstrumentation Design 588 9.15 Exercises 591 10. Biomedical Sensors YITZHAK MENDELSON 10.1 Introduction 610 10.2 Biopotential Measurements 616 10.3 Physical Measurements 621 10.4 Blood Gas Sensors 639 10.5 Bioanalytical Sensors 647 10.6 Optical Sensors 651 10.7 Exercises 662 11. Biosignal Processing MONTY ESCABI 11.1 Introduction 668 11.2 Physiological Origins of Biosignals 668 11.3 Characteristics of Biosignals 671 11.4 Signal Acquisition 674 11.5 Frequency Domain Representation of Biological Signals 679 11.6 Linear Systems 700 11.7 Signal Averaging 721 viii CONTENTS
- 15. 11.8 The Wavelet Transform and the Short-Time Fourier Transform 727 11.9 Artificial Intelligence Techniques 732 11.10 Exercises 741 12. Bioelectric Phenomena JOHN D. ENDERLE 12.1 Introduction 748 12.2 History 748 12.3 Neurons 756 12.4 Basic Biophysics Tools and Relationships 761 12.5 Equivalent Circuit Model for the Cell Membrane 773 12.6 The Hodgkin-Huxley Model of the Action Potential 783 12.7 Model of a Whole Neuron 797 12.8 Chemical Synapses 800 12.9 Exercises 808 13. Physiological Modeling JOHN D. ENDERLE 13.1 Introduction 818 13.2 An Overview of the Fast Eye Movement System 821 13.3 The Westheimer Saccadic Eye Movement Model 828 13.4 The Saccade Controller 835 13.5 Development of an Oculomotor Muscle Model 838 13.6 The 1984 Linear Reciprocal Innervation Saccadic Eye Movement Model 852 13.7 The 1995 Linear Homeomorphic Saccadic Eye Movement Model 864 13.8 The 2009 Linear Homeomorphic Saccadic Eye Movement Model 878 13.9 Saccade Neural Pathways 905 13.10 System Identification 910 13.11 Exercises 927 14. Biomedical Transport Processes GERALD E. MILLER 14.1 Biomedical Mass Transport 938 14.2 Biofluid Mechanics and Momentum Transport 957 14.3 Biomedical Heat Transport 975 14.4 Exercises 992 15. Radiation Imaging JOSEPH D. BRONZINO 15.1 Introduction 995 15.2 Emission Imaging Systems 997 15.3 Instrumentation and Imaging Devices 1013 15.4 Radiographic Imaging Systems 1018 15.5 Exercises 1037 16. Medical Imaging THOMAS SZABO 16.1 Introduction 1040 16.2 Diagnostic Ultrasound Imaging 1042 16.3 Magnetic Resonance Imaging 1071 16.4 Magnetoencephalography 1099 16.5 Contrast Agents 1101 16.6 Comparison of Imaging Modes 1103 16.7 Image Fusion 1106 16.8 Summary 1107 16.9 Exercises 1108 17. Biomedical Optics and Lasers GERARD L. COTÉ, LIHONG V. WANG, AND SOHI RASTEGAR 17.1 Introduction to Essential Optical Principles 1112 17.2 Fundamentals of Light Propagation in Biological Tissue 1118 17.3 Physical Interaction of Light and Physical Sensing 1130 17.4 Biochemical Measurement Techniques Using Light 1139 17.5 Fundamentals of the Photothermal Therapeutic Effects of Light Sources 1147 17.6 Fiber Optics and Waveguides in Medicine 1158 17.7 Biomedical Optical Imaging 1165 17.8 Exercises 1170 Appendix 1175 Index 1213 ix CONTENTS
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- 17. Preface The purpose of the third edition remains the same as the first and second editions, that is, to serve as an introduction to and overview of the field of biomedical engi- neering. Many chapters have undergone major revision from the previous editions with new end-of-chapter problems added. Some chapters were eliminated completely, with several new chapters added to reflect changes in the field. Over the past fifty years, as the discipline of biomedical engineering has evolved, it has become clear that it is a diverse, seemingly all-encompassing field that includes such areas as bioelectric phenomena, bioinformat- ics, biomaterials, biomechanics, bioinstru- mentation, biosensors, biosignal processing, biotechnology, computational biology and complexity, genomics, medical imaging, optics and lasers, radiation imaging, tissue engineering, and moral and ethical issues. Although it is not possible to cover all of the biomedical engineering domains in this textbook, we have made an effort to focus on most of the major fields of activity in which biomedical engineers are engaged. The text is written primarily for engineer- ing students who have completed differen- tial equations and a basic course in statics. Students in their sophomore year or junior year should be adequately prepared for this textbook. Students in the biological sciences, including those in the fields of medicine and nursing can also read and understand this material if they have the appropriate mathematical background. Although we do attempt to be fairly rigor- ous with our discussions and proofs, our ulti- mate aim is to help students grasp the nature of biomedical engineering. Therefore, we have compromised when necessary and have occasionally used less rigorous mathematics in order to be more understandable. A liberal use of illustrative examples amplifies con- cepts and develops problem-solving skills. Throughout the text, MATLAB® (a matrix equation solver) and SIMULINK® (an exten- sion to MATLAB® for simulating dynamic systems) are used as computer tools to assist with problem solving. The Appendix pro- vides the necessary background to use MATLAB® and SIMULINK®. MATLAB® and SIMULINK® are available from: The Mathworks, Inc. 24 Prime Park Way Natick, Massachusetts 01760 Phone: (508) 647-7000 Email: info@mathworks.com WWW: http:/ /www.mathworks.com Chapters are written to provide some his- torical perspective of the major developments in a specific biomedical engineering domain as well as the fundamental principles that underlie biomedical engineering design, anal- ysis, and modeling procedures in thatdomain. In addition, examples of some of the problems encountered, as well as the techniques used to solve them, are provided. Selected problems, ranging from simple to difficult, are presented at the end of each chapter in the same general order as covered in the text. xi
- 18. The material in this textbook has been designed for a one-semester, two-semester, or three-quarter sequence depending on the needs and interests of the instructor. Chapter 1 provides necessary background to understand the history and appreciate the field of bio- medical engineering. Chapter 2 presents the vitallyimportantchapteronbiomedicallybased morals and ethics. Basic anatomy and physiol- ogy are provided in Chapter 3. Chapters 4–11 provide the basic core biomedical engineering areas: biomechanics, biomaterials, tissue engi- neering, compartmental modeling, biochemical reactions, bioinstrumentation, biosensors, and biosignal processing. To assist instructors in planning the sequence of material they may wish to emphasize, it is suggested that the chapters on bioinstrumentation, biosensors and biosignal processing should be covered together as they are interdependent on each other. The remainder of the textbook presents material on biomedical systems and biomedical technology (Chapters 12–17). Readers of the text can visit http:/ /www .elsevierdirect.com/9780123749796 to view extra material that may be posted there from time to time. Instructors can register at http:/ /www .textbooks.elsevier.com for access to solu- tions and additional resources to accompany the text. ACKNOWLEDGMENTS Many people have helped us in writing this textbook. Well deserved credit is due to the many contributors who provided chapters and worked under a very tight timeline. Special thanks go to our publisher, Elsevier, especially for the tireless work of the Publisher, Joseph Hayton and Associate Editor, Steve Merken. In addition, we appreciate the work of Lisa Lamenzo, the Project Manager. A great debt of gratitude is extended to Joel Claypool, the editor of the first edition of the book and Diane Grossman from Aca- demic Press, and Christine Minihane, the editor of the second edition. Also, we wish to acknowledge the efforts of Jonathan Simpson, the first editor of this edition, who moved onto to other assignments before this project was complete. A final and most important note concerns our co-author of the first two editions of this book, Susan Blanchard. She decided that she wanted to devote more time to her family and not to continue as a co-author. xii PREFACE
- 19. Contributors to the Third Edition Susan M. Blanchard Florida Gulf Coast University, Fort Meyers, Florida Joseph D. Bronzino Trinity College, Hartford, Connecticut Stanley A. Brown Food and Drug Administration, Gaithersburg, Maryland Gerard L. Coté Texas A&M University, College Station, Texas Robert Dennis University of North Carolina, Chapel Hill, North Carolina John Enderle University of Connecticut, Storrs, Connecticut Monty Escabı́ University of Connecticut, Storrs, Connecticut Liisa T. Kuhn University of Connecticut Health Center, Farmington, Connecticut Jeffrey M. Macdonald University of North Carolina-Chapel Hill, Chapel Hill, North Carolina Randall McClelland University of North Carolina, Chapel Hill, North Carolina Yitzhak Mendelson Worcester Polytechnic Institute, Worcester, Massachusetts Katharine Merritt Food and Drug Administration, Gaithersburg, Maryland Gerald E. Miller Virginia Commonwealth University, Richmond, Virginia Joseph Palladino Trinity College, Hartford, Connecticut Bernard Palsson University of California at San Diego, San Diego, California Sohi Rastegar National Science Foundation, Arlington, Virginia Lola M. Reid University of North Carolina, Chapel Hill, North Carolina Kirk K. Shung University of Southern California, Los Angeles, California Jan P. Stegemann University of Michigan, Ann Arbor, Michigan Thomas Szabo Boston University, Boston, Massachusetts LiHong V. Wang Washington University in St. Louis, St. Louis, Missouri xiii
- 20. Contributors to the Second Edition Susan M. Blanchard Florida Gulf Coast University, Fort Meyers, Florida Joseph D. Bronzino Trinity College, Hartford, Connecticut Stanley A. Brown Food and Drug Administration, Gaithersburg, Maryland Gerard L. Coté Texas A&M University, College Station, Texas Charles Coward Drexel University, Philadelphia, Pennsylvania Roy B. Davis III Shriners Hospital for Children, Greenville, South Carolina Robert Dennis University of North Carolina, Chapel Hill, North Carolina John Enderle University of Connecticut, Storrs, Connecticut Monty Escabı́ University of Connecticut, Storrs, Connecticut Robert J. Fisher University of Massachusetts, Amherst, Massachusetts Liisa T. Kuhn University of Connecticut Health Center, Farmington, Connecticut Carol Lucas University of North Carolina- Chapel Hill, Chapel Hill, North Carolina Jeffrey M. Macdonald University of North Carolina-Chapel Hill, Chapel Hill, North Carolina Amanda Marley North Carolina State University, Raleigh, North Carolina Randall McClelland University of North Carolina, Chapel Hill, North Carolina Yitzhak Mendelson, PhD Worcester Polytechnic Institute, Worcester, Massachusetts Katharine Merritt Food and Drug Administration, Gaithersburg, Maryland Spencer Muse North Carolina State University, Raleigh, North Carolina H. Troy Nagle North Carolina State University, Raleigh, North Carolina Banu Onaral Drexel University, Philadelphia, Pennsylvania Joseph Palladino Trinity College, Hartford, Connecticut Bernard Palsson University of California at San Diego, San Diego, California Sohi Rastegar National Science Foundation, Arlington, Virginia Lola M. Reid University of North Carolina, Chapel Hill, North Carolina Kirk K. Shung University of Southern California, Los Angeles, California Anne-Marie Stomp North Carolina State University, Raleigh, North Carolina Thomas Szabo Boston University, Boston, Massachusetts Andrew Szeto San Diego State University, San Diego, California LiHong V. Wang Washington University in St. Louis, St. Louis, Missouri Melanie T. Young North Carolina State University, Raleigh, North Carolina xiv
- 21. Contributors to the First Edition Susan M. Blanchard Florida Gulf Coast University, Fort Meyers, Florida Joseph D. Bronzino Trinity College, Hartford, Connecticut Stanley A. Brown Food and Drug Administration, Gaithersburg, Maryland Gerard L. Coté Texas A&M University, College Station, Texas Roy B. Davis III Shriners Hospital for Children, Greenville, South Carolina John Enderle University of Connecticut, Storrs, Connecticut Robert J. Fisher University of Massachusetts, Amherst, Massachusetts Carol Lucas University of North Carolina- Chapel Hill, Chapel Hill, North Carolina Amanda Marley North Carolina State University, Raleigh, North Carolina Yitzhak Mendelson, PhD Worcester Polytechnic Institute, Worcester, Massachusetts Katharine Merritt Food and Drug Administration, Gaithersburg, Maryland H. Troy Nagle North Carolina State University, Raleigh, North Carolina Joseph Palladino Trinity College, Hartford, Connecticut Bernard Palsson University of California at San Diego, San Diego, California Sohi Rastegar National Science Foundation, Arlington, Virginia Daniel Schneck Virginia Polytechnic Institute & State University, Blacksburg, Virginia Kirk K. Shung University of Southern California, Los Angeles, California Anne-Marie Stomp North Carolina State University, Raleigh, North Carolina Andrew Szeto San Diego State University, San Diego, California LiHong V. Wang Washington University in St. Louis, St. Louis, Missouri Steven Wright Texas A&M University, College Station, Texas Melanie T. Young North Carolina State University, Raleigh, North Carolina xv
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- 23. C H A P T E R 1 Biomedical Engineering: A Historical Perspective Joseph D. Bronzino, PhD, PE O U T L I N E 1.1 The Evolution of the Modern Health Care System 2 1.2 The Modern Health Care System 9 1.3 What Is Biomedical Engineering? 16 1.4 Roles Played by the Biomedical Engineers 21 1.5 Recent Advances in Biomedical Engineering 23 1.6 Professional Status of Biomedical Engineering 29 1.7 Professional Societies 30 1.8 Exercises 32 Suggested Readings 33 AT THE CONCLUSION OF THIS CHAPTER, STUDENTS WILL BE ABLE TO: • Identify the major role that advances in medical technology have played in the establishment of the modern health care system. • Define what is meant by the term biomedical engineering and the roles biomedical engineers play in the health care delivery system. • Explain why biomedical engineers are professionals. 1 Introduction to Biomedical Engineering, Third Edition # 2012 Elsevier Inc. All rights reserved.
- 24. In the industrialized nations, technological innovation has progressed at such an acceler- ated pace that it has permeated almost every facet of our lives. This is especially true in the area of medicine and the delivery of health care services. Although the art of medicine has a long history, the evolution of a technologically based health care system capable of providing a wide range of effective diagnostic and therapeutic treatments is a relatively new phenomenon. Of particular importance in this evolutionary process has been the estab- lishment of the modern hospital as the center of a technologically sophisticated health care system. Since technology has had such a dramatic impact on medical care, engineering profes- sionals have become intimately involved in many medical ventures. As a result, the disci- pline of biomedical engineering has emerged as an integrating medium for two dynamic professions—medicine and engineering—and has assisted in the struggle against illness and disease by providing tools (such as biosensors, biomaterials, image processing, and artificial intelligence) that health care professionals can use for research, diagnosis, and treatment. Thus, biomedical engineers serve as relatively new members of the health care delivery team that seeks new solutions for the difficult problems confronting modern society. The purpose of this chapter is to provide a broad overview of technology’s role in shaping our modern health care system, highlight the basic roles biomedical engineers play, and present a view of the professional status of this dynamic field. 1.1 THE EVOLUTION OF THE MODERN HEALTH CARE SYSTEM Primitive humans considered diseases to be “visitations”—the whimsical acts of affronted gods or spirits. As a result, medical practice was the domain of the witch doctor and the medicine man and medicine woman. Yet even as magic became an integral part of the heal- ing process, the cult and the art of these early practitioners were never entirely limited to the supernatural. Using their natural instincts and learning from experience, these indivi- duals developed a primitive science based upon empirical laws. For example, through acquisition and coding of certain reliable practices, the arts of herb doctoring, bone setting, surgery, and midwifery were advanced. Just as primitive humans learned from observation that certain plants and grains were good to eat and could be cultivated, the healers and shamans observed the nature of certain illnesses and then passed on their experiences to other generations. Evidence indicates that the primitive healer took an active, rather than simply intuitive, interest in the curative arts, acting as a surgeon and a user of tools. For instance, skulls with holes made in them by trephiners have been collected in various parts of Europe, Asia, and South America. These holes were cut out of the bone with flint instruments to gain access to the brain. Although one can only speculate the purpose of these early surgical operations, magic and religious beliefs seem to be the most likely reasons. Perhaps this procedure liberated from the skull the malicious demons that were thought to be the cause of extreme pain (as in the case of migraines) or attacks of falling to the ground (as in epilepsy). That this procedure was carried out on living patients, some of whom actually survived, is 2 1. BIOMEDICAL ENGINEERING
- 25. evident from the rounded edges on the bone surrounding the hole, which indicate that the bone had grown again after the operation. These survivors also achieved a special status of sanctity so that, after their death, pieces of their skull were used as amulets to ward off convulsive attacks. From these beginnings, the practice of medicine has become integral to all human societies and cultures. It is interesting to note the fate of some of the most successful of these early practitioners. The Egyptians, for example, have held Imhotep, the architect of the first pyramid (3000 BC), in great esteem through the centuries, not as a pyramid builder but as a doctor. Imhotep’s name signified “he who cometh in peace” because he visited the sick to give them “peaceful sleep.” This early physician practiced his art so well that he was deified in the Egyptian culture as the god of healing. Egyptian mythology, like primitive religion, emphasized the interrelationships between the supernatural and one’s health. For example, consider the mystic sign Rx, which still adorns all prescriptions today. It has a mythical origin: the legend of the Eye of Horus. It appears that as a child Horus lost his vision after being viciously attacked by Seth, the demon of evil. Then Isis, the mother of Horus, called for assistance to Thoth, the most important god of health, who promptly restored the eye and its powers. Because of this intervention, the Eye of Horus became the Egyptian symbol of godly protection and recov- ery, and its descendant, Rx, serves as the most visible link between ancient and modern medicine. The concepts and practices of Imhotep and the medical cult he fostered were duly recorded on papyri and stored in ancient tombs. One scroll (dated c. 1500 BC), which George Elbers acquired in 1873, contains hundreds of remedies for numerous afflictions ranging from crocodile bites to constipation. A second famous papyrus (dated c. 1700 BC), discovered by Edwin Smith in 1862, is considered to be the most important and complete treatise on surgery of all antiquity. These writings outline proper diagnoses, prognoses, and treatment in a series of surgical cases. These two papyri are certainly among the outstanding writings in medical history. As the influence of ancient Egypt spread, Imhotep was identified by the Greeks with their own god of healing: Aesculapius. According to legend, the god Apollo fathered Aesculapius during one of his many earthly visits. Apparently Apollo was a concerned parent, and, as is the case for many modern parents, he wanted his son to be a physician. He made Chiron, the centaur, tutor Aesculapius in the ways of healing (Figure 1.1). Chiron’s student became so proficient as a healer that he soon surpassed his tutor and kept people so healthy that he began to decrease the population of Hades. Pluto, the god of the underworld, complained so violently about this course of events that Zeus killed Aesculapius with a thunderbolt and in the process promoted Aesculapius to Olympus as a god. Inevitably, mythology has become entangled with historical facts, and it is not certain whether Aesculapius was in fact an earthly physician like Imhotep, the Egyptian. However, one thing is clear: by 1000 BC, medicine was already a highly respected profession. In Greece, the Aesculapia were temples of the healing cult and may be considered the first hospitals (Figure 1.1). In modern terms, these temples were essentially sanatoriums that had strong religious overtones. In them, patients were received and psychologically prepared, through prayer and sacrifice, to appreciate the past achievements of Aesculapius and his physician priests. After the appropriate rituals, they were allowed to enjoy “temple sleep.” During 3 1.1 THE EVOLUTION OF THE MODERN HEALTH CARE SYSTEM
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- 27. and departure from these places were always effected secretly and at night. By these means it became possible to the French officers to have some idea of what was going on in the lower Yen-Thé, but the knowledge obtained concerning the strength and situation of the rebels' fortified positions in the north was extremely vague. A NATIVE SPY. Several of the spies had made attempts to penetrate into the region north of Ha-Thuong. Some were turned back; others, who had probably excited suspicion, were tortured and decapitated; but none of them succeeded in obtaining a glimpse of the strongholds, or in gaining any certitude concerning the paths which led to them. However, thanks to these spies, it became known that important convoys of grain and food stuffs, coming from the villages near Bac- Ninh, were sent northwards twice a week, by paths which passed a little to the west of our position, and were not visible from it. The usual time for the passage of these supplies near Nha-Nam was
- 28. from one to three in the afternoon, at which hour, owing to the heat, the troops were under cover. Acting on orders received from General Voyron, who had just taken over the command of the 2nd Brigade at Bac-Ninh, small parties were sent out on several occasions in hopes of surprising the convoy. They were concealed in one of the deserted villages along the paths supposed to be frequented by the rebels, and at points from which a good view of the track for some distance could be obtained. I took part several times in these small expeditions. One of them is perhaps worthy of mention, since it provided some excitement for all those who assisted in it. Our detachment on this occasion consisted of eight Legionaries, and as many tirailleurs, under the order of a corporal of our regiment. We proceeded due south about 3 miles along the high road to Cao- Thuong to a fine pagoda, the wall of which skirted the highway. Just facing the entrance to the building, and at right angles to the main road which it joined, was a small path that ran across the fields to the west, and was visible for about 400 yards, afterwards turning off sharp to the left behind a range of small hillocks covered with long grass. At the apex of the angle formed by the junction of this path and the main road was a big banyan tree with a clump of bushes at its base. It was here that our ambuscade was placed, after a scouting party had gone through a big empty village, situated just behind the pagoda, and it was certain that there existed no sign of occupation, or trace of a recent passage of the enemy. Six Legionaries, two natives and the corporal remained behind the pagoda wall, and through the open brickwork in the top part of it they could see across the fields. Together with four tirailleurs I was posted on the opposite side of the road. We were a little to the right of the others, our backs towards them, behind the clump of bushes at the foot of the banyan.
- 29. Perched up on one of the branches of this tree and concealed by its dense foliage was a Legionary, who, from the position he occupied, obtained a fine view to the south and west: these being the only directions from which our position could be approached, since the bamboo hedge of the village behind us skirted the road to the east for at least 500 yards, and nothing could come from the north without being seen by our sentries at Nha-Nam, who had received orders to keep a sharp look-out. It was ten in the morning before we had settled down. Our instructions were to reserve our fire, and, if possible, capture one of the enemy alive. The heat was terrible—this was in the second week in June, and the rains had not broken—and although, thanks to the shade from the tree above me, I could doff my helmet and profit by the occasional light puffs of breeze, just sufficient to move the airy foliage of the bamboo, it required all my energy to fight against the invading drowsiness. From time to time I would question the man in the tree in the hope that he would announce the advent of a troop; but he disappointed me each time with a reply in the negative. My attention was soon drawn to the four natives beside me, for I perceived that they were fast asleep. The natives possess a faculty of dropping into a sound slumber without respect to time or position; and these, though seated, their bodies bolt upright and their legs crossed before them, were snoring. The Tonquinese, like the Arabs, have a proverb which says: "A man is better sitting than standing, better asleep than sitting, and better dead than asleep." However, this was no time to ponder on the ethics of Oriental philosophy, so I applied myself to awakening these weary ones, and, after a good deal of vigorous shaking, succeeded in doing so. The corporal, who from his hiding-place had taken in the situation, adjured me, in low but energetic tones, to make use of the butt of my rifle to infuse enthusiasm into the unfortunate tirailleurs. Then all was quiet again, and our weary watching was resumed.
- 30. The time seemed to drag along with painful slowness, and the glare and heat increased in intensity. Hardly a sound disturbed the drowsy tranquillity, and had it not been for the chirping song of the cicalas and the far-away whistle of a kite, which soared above us and whose shadow flitted occasionally across the open ground in front, one could have imagined that there was nothing living for miles around. The sun began to move westwards, and its rays struck the white wall behind me, only to be reflected with such force that I was obliged to put on my helmet to protect the back of my head. It was nearly two in the afternoon when we were startled by a short exclamation from the sentry perched above us. "What is it?" somebody enquired. "There is something moving," he replied, "a long way off—two kilomètres, perhaps—two men—Ah! there are some who carry baskets. Nhaques (peasants) going to market, I suppose." Then with growing excitement in his tone he continued: "I see a glitter. Got for deck!" (he was a Belgian). "The two men in front carry rifles—they are the point! Yes! Yes! the point! Further back there are more coolies with baskets, and more men with rifles—now two men on ponies." "Where are they?" I tried to speak quietly, but could have shouted with excitement. "On the path which runs behind the hillocks—the path which turns in here. They come from the south, and walk very quickly. Wheew!" he whistled, "there are quite sixty coolies, and as many men with guns. They have a rear-guard. The first will be on the path before us in ten minutes. Prévenez vite le caporal—Nous allons rire!" I ran across the road behind us, through the gateway into the pagoda yard, and informed our "non-com." Though he was only half awake when I began—for the heat had been too much for him—he was quite alive to the situation before I had said many words, and almost shook hands with me in his joy at the news.
- 31. "Don't shoot," he said, "unless they are alarmed and run, then shoot straight. Let them come up on the road here and we can collar one, mais pour l'amour de Dieu! Keep an eye on your demoiselles—I have no faith in them!" I went back to my hiding-place. Hellincks, the man in the tree, said to me: "Hurry up! The two first will be round the corner in a minute or so." I glanced at the tirailleurs. They were kneeling now, and throwing eager glances through the foliage. In a low voice I told them to fix bayonets and load, and noticed that the man next to me trembled like a leaf as he did so. Excitement, I thought—or was it fear? From a deep bronze his skin had changed to a dirty yellow. I should have known and taken away his weapon, but this was my first experience. Mechanically I slipped my right hand into the pouch of my belt, took out a cartridge, and after wetting the bullet with my tongue, slipped it into the open breech of my rifle and closed it. Now nothing moved, and the only sounds that struck the ear were the song of the cicalas, the whistle of the kite, and the gentle rustle of the bamboos in the breeze. Suddenly, round the corner of the last hillock, came a man; then, a yard or so behind, another. Though expected, their actual appearance produced an impression of surprise; perhaps because we had waited so long. Both wore a kind of uniform of green cotton cloth, and putties of the same colour. Their long hair was rolled in a silken turban of similar hue. Hanging on his shoulders, suspended by a string which passed round the front of his neck, each man had a big palm-leaf hat. The sun glittered on their brass cartridges fixed in a belt round the waist, and on the Winchesters which they carried on the shoulder, as a gardener carries his spade; the end of the muzzle in the hand, the butt behind them.
- 32. On they came at a sort of jog-trot, and we could hear the pad! pad! pad! of their naked feet on the hot path. Now they were within 100 yards of us, and I fancied I could perceive a look of relief on the ugly flat features of the first as he glanced towards the pagoda. The first of the long string of bearers with their bamboo and baskets were now visible, coming along at a jerky run. I felt something touch my left elbow, and glanced round to find that Hellincks had come down from his perch and was kneeling beside me. The two armed men were quite near now. We could see a bead of perspiration on the face of the first as it came from his hair and trickled down his forehead. We could hear the regular, short pant of his hard breathing, note his half-open mouth, and distinguish his black-lacquered teeth. Pad! pad! pad!—a soft puff of breeze brought to my nostrils the acrid odour of the perspiring native. Another few seconds, and by thrusting my rifle through the leaves I could have touched his breast with the muzzle. These two will surely be ours; nothing can save them! Unable to control himself, mastered by excitement or fear, the tirailleur on my right suddenly sprang to his feet, and shouted in the vernacular: "Toi!" ("Stop!") "Adow di?" ("Where go you?") From the pagoda behind us I heard an angry murmur, and could distinguish the corporal's voice: "Kill the swine! Oh, kill him!"— Hellincks cursed and groaned like a man struck with fever. I felt that I had stopped sweating, and a big lump rose from my chest into my throat, and seemed to choke me. I gave a great sob of disappointment and surprise. The next instant we were on our feet, for Hellincks rose with me, and as he shouted, "We can yet catch one," I knew that he had a similar thought to mine. But we had hardly taken the first step
- 33. forward, prior to forcing our way through the bushes and jumping down into the paddy field, than we were blinded for a second by two bright flashes from a few feet in front of us, and half deafened by the close report of the rebels' Winchesters. The linh (native soldier), the cause of all the racket, pitched head foremost into the foliage. There was no time to lose, so both of us rushed through the little cloud of smoke, through the bushes, and the next instant we were down in the field. Fifteen, perhaps twenty, yards away I saw the backs of the two green-clad natives who were running for dear life. They were side by side in the field, for the path was littered with the baskets and bamboos of the coolies, who had disappeared as if by magic. "Too late!" I shouted. Hellincks jerked up his rifle and covered the native on the left. The next instant, acting on his example, I was peeping along my sights and bringing them in line on to the middle of the palm-leaf hat, which bumped as it hung on the receding back of the man to the right. Before I could press the trigger Hellincks had fired, and a cloud of smoke floated across my line of vision. It was gone in a second, and I got my chance. Through the white puff from my rifle I saw a dark figure spring into the air with the pose of a marionette of which all the strings have been jerked together; and, as I brought down my weapon, jerked out the empty cartridge and reloaded, I saw a dark mass lying motionless on the damp ground amongst the bright green stalks of young rice. "Vite! vite! you fool, mine is winged, and will escape if you do not hurry!" cried my comrade, as he started off at the double. On we ran for about 30 yards; then Hellincks stopped, and, pointing to the ground, jerked out: "I told you so"; and I saw a small blotch the size of a man's hand, which, as the bright sunshine played upon it, glittered red like a splendid dark ruby. "These fellows have as many lives as a cat," he continued hurriedly. "He was down and up again in a second; limped away across the
- 34. path into that tall grass on the right"—pointing in that direction. "Come! we may yet have him." On we went a few more yards, when the Belgian came a cropper, having tripped over the foot of the thing spread-eagled in the rice field. In his hurry he had passed too close. I had given it a wide berth. I came back to help him up, and had to look at it. There was a small round hole in the back of the neck, just below the base of the skull. Hellincks scrambled up, panting. How he cursed! "What are you staring at, man? Take his gun—quick!" Bending down, I picked up the Winchester. In doing so I almost touched the body, and with difficulty suppressed a murmured, "I beg your pardon," because I was dominated by a sentiment of awesome respect for the thing that had been, and was no more. I wished to walk softly, on tiptoe, and felt so thankful that he had fallen face- downwards. All this had passed in the space of a few seconds. "Come back! come back!" It was the corporal shouting to us, and there was a note of warning in his voice. Before turning to go I glanced up, and saw a puff of white smoke arise, float for a second over the top of the hillock ahead, and I heard a report. Something struck the wet ground a little in front and to my right. A speck of mud hit me on the chin; then, along a distance of 50 yards or so, the crest was covered with smoke, and there was a rattle of musketry. As we ran the ground and the air seemed to me to be alive, and I could not go quickly enough to please myself. Hellincks said between pants: "We forgot the cartridges." "Oh! d—- the cartridges!" I replied, and it was as if some one else had said it.... How far it seemed!—there were not more than 40 yards. How hot the sun was! I believe I was terribly afraid during the few seconds it took us to get back to shelter again.
- 35. How we got back I don't remember; I only know that I felt quite surprised to find myself standing, somewhat blown, behind the big tree, telling my "non-com" what had happened, and feeling very anxious not to appear flustered. Hellincks lay panting and laughing on the grass beside the other men—three Legionaries, who were making caustic remarks concerning our running powers, and five tirailleurs. The latter were either kneeling sheltered by the tree, or extended flat on the road, their rifles ready to reply to the enemy's fire, which was increasing in intensity. To my explanation the corporal replied: "Bon! bon! It was the fault of that dog of a native. Pity he was not hit—killed. They shot off his sakalo, and he fainted. Three of our fellows and two tirailleurs are behind the pagoda wall to the right; they can see the enemy's position from there. Go and take command of them" (I was an élève-caporal—i.e., lance-corporal—at this time), "and follow up each volley we fire from here by another— distance, 300 yards." I went over to my little command, my nerves steadied by the thought of the responsibility which was now mine. I lined the men up, each before an aperture in the open brickwork of the wall, and recommended them to aim carefully, and wait for the word of command before firing. Half sitting, half lying, with his head against the wall, was the tirailleur who had been the cause of our abortive ambuscade. The upper half of his face was scorched and blackened, and a little red stream trickled down from forehead to chin. He looked dazed and stupid, and his eyes were half closed. From his lips came a continual moan, which he interrupted every few seconds to murmur: "Tiet! Tiet!" ("Dead! Dead!") My attention was called from him by the crash of a volley from the corporal's party.
- 36. As soon as the smoke had risen the smart rattle of our volley rang out. Three times I gave the same commands, and each detonation seemed an echo to the one from the rifles of our comrades. Then there was a pause. The enemy's fire had slackened considerably, and the noise of the projectiles as they struck the wall and roof of the pagoda, sang overhead or clattered through the branches of the banyan, was hardly noticeable when compared to the racket they had kept up a few minutes before. From the hillocks before us only occasional puffs of smoke arose, followed by isolated reports from their rifles. At his call I went out to our "non-com," who said: "They seem to be sick of it, and certainly show no disposition to rush us. I wish they would try, Sacré bleu! The ground is too open for them. If we could depend on the linhs—but we can't—we might make a dash for the convoy; without them the odds are too great, so I have decided to withdraw. I will start off with this lot. When we have got away give them a volley to keep them still; and if they show any signs of moving, a little independent firing. Don't be extravagant, though. You understand?" PAGODA USED FOR AMBUSH. [See page 139.] "Yes," I answered. "But you must take that wounded linh; he would hamper me."
- 37. "Of course," he replied. "Sacré bon Dieu! I had forgotten the coward. Can he stand?" "I don't think so." Thereupon he told two men off to fetch the poor beggar, and I felt sorry for him when he appeared tottering, though supported by the two Legionaries. As already explained, the banyan tree and the bushes masked the pagoda gateway, so that these movements could not be seen by the enemy. "He'll do," said the corporal. "You two men hold on to him, and help him to keep up. Here you"—this to another tirailleur—"tell him to run his best when we go." This was explained; and he nodded, mumbled, and would have started off alone if he had not been held. He seemed in a hurry to get away, and we all laughed. "Now," said our chief, "the Brigade will retire by echelons." Then, with a grin and a bow to me: "You, monsieur, will cover our withdrawal with your battalion. When you hear a volley from us, double out and rejoin with your party. Good luck to you!" "Bonne chance!" I replied, and went back to my men. A couple of sharp orders, and the others clattered by at the double. The next minute the enemy's fire broke out with renewed vigour. They probably thought that everybody had left, for no bullets came our way. Crash! went our volley at them, but they still kept it up: the running white men were too tempting a target. I waited half a minute, and ordered independent firing of four cartridges per man, and joined in the fun. This calmed them a little, and I got my men outside, sheltered behind the friendly banyan, ready for the run, as it was probable that the others would soon halt.
- 38. The road went off slightly to the right, and was hidden from view by the corner of the wall. We had not long to wait, for in a few seconds the rattle of the rifles told me it was time to start, so away we went in single file at the run. We found the first detachment sheltered behind a ridge between two fields, from whence they had fired two volleys to cover our withdrawal. No one had been hit, the only damage done being to the stock of a rifle belonging to a man who had retreated with me, which had been smashed by a rifle bullet. There can be no doubt that the rebels were very poor shots at anything over 100 yards; and it is doubtful if any of them knew how to hit a running object. It was not for us to grumble at this, however. Their fire ceased completely, as soon as we had joined forces. This was due, probably, to the fact that, owing to the continued sound of firing, the picquet from Nha-Nam had been sent out to meet us— though we were unaware of this, as a slight rise of the ground hid the fort from us. We moved off cautiously, and very soon met the relief. This detachment, about fifty strong, went on in hope of engaging the enemy, but were disappointed; for, although they occupied the hillocks from which we had been fired upon, the rebels had not waited for them but retreated, together with the convoy, leaving behind them but a few baskets of rice. So terminated my first experience under fire from a visible enemy. That night we were awakened, and remained under arms for an hour, for the enemy amused themselves by treating us to a long range fire. It was a waste of ammunition, for nobody was hurt, and we did not reply. Some of my comrades suggested that this was a reprisal for our ambuscade of the afternoon. Personally, I am inclined to believe that it was a feinted attack on our position, designed to engage our attention, and ensure the passage of the belated convoy which had escaped us. The weather now grew hotter every day, and several cases of heat, apoplexy and fever occurred in our little garrison. It is probable that the fever was due to the digging which had taken place during the construction of our fortifications. This was inevitable, of course; but
- 39. it is always very dangerous to break new soil in these districts, since the surface to the depth of 3 or 4 feet is mainly composed of decayed vegetation in which the malaria microbe is abundant. All the newcomers were, of course, victims to prickly-heat, in addition to which many of us were afflicted with small boils. These would not come one or two at a time, but sufferers were literally covered with them. I was one of the first to pay toll to this extremely painful malady. In addition to these unavoidable inconveniences, the whole company suffered from another discomfort which was a cause of deep complaint on the part of the men, since it was due to the neglect of our commissariat department. Because some trifling formality had not been executed, mosquito-nets were not served out to us till late in July, and the lack of them caused many hours of sleepless agony during the hot nights. A surprising amount of red-tapeism still remained in the commissariat department of France's colonial army; and, though this branch was remodelled at the beginning of 1901, it is generally acknowledged that the authorities responsible for the new order of things have obtained little or no improvement in this respect. In July the heat became tremendous; the afternoons, which were the hottest part of the day, averaging 110 degrees in the shade. The men were kept indoors from nine in the morning until three in the afternoon, and operations were restricted to short reconnaissances, which took place either in the early morning or in the evening. These excursions were always made to the south, east or west, but not northwards, as orders had been received from the Brigade to abstain from penetrating into the enemy's country until the summer months had passed. In consequence, the garrison of Nha-Nam disposed of a good deal of leisure time, which the men made use of according to their varied tastes. Making cloth belts embroidered with flags and other warlike devices was a favourite pastime with many; books and newspapers were in great demand, and a fortnightly convoy from Phulang-Thuong, which
- 40. brought the European mail, was an incident of importance to all. A rifle range had been built about 500 yards to the west of our position, and each morning saw some unit of the garrison at practice. Close to the fort, on the south-west side, was a small village inhabited by the camp followers, wives and children of some of the native troops. It contained one small store kept by a Chinaman, at which the troops could obtain tobacco, tinned goods, and strong drinks. The sale of intoxicants was, however, subjected to strict regulation, any infringement of which would have entailed the peremptory closing of the storekeeper's establishment. The men not on duty were allowed to go into the village from 5 to 7 p.m. only, so that would-be topers had small facilities for over-indulgence, and cases of drunkenness were few and far between. Thirsty souls could obtain good wine from the Government stores in the fort at a very reasonable price, though this supply was with reason restricted to half a litre (a little more than a pint) a day per man. Our diet was good, for the natives from some of the surrounding villages brought in a plentiful supply of eggs, poultry, pork, fruit and yams, which were readily purchased, as the troops received a mess- grant in addition to their daily ration of bread, fresh meat, coffee, sugar, rice and salt. During the period of comparative inaction, and profiting by the leisure at my disposal, I made an attempt at learning the Annamese language. Progress was very slow, for the vernacular, like Chinese, is composed of a multitude of sounds, many of which are so similar to each other that only a well-trained ear can distinguish the difference; also, there exists neither alphabet nor grammar to aid the student, and success depends entirely on the possession of a good memory, and inexhaustible patience. In writing this language the natives use the Chinese characters, each representing a sound; and the extent of knowledge of their literati
- 41. class is gauged by the number of these each individual has succeeded in retaining. Thus a native who has passed examinations which prove that he possesses five thousand characters, is said to be clever; and one who has shown that he can make use of double that quantity is considered to have reached a very high standard of education indeed. As in the Chinese and Japanese languages many words possess an honorific as well as a common form. Thus an official, in speaking to an inferior, will refer to himself by using the word tao (I); but in conversing with a superior this form of pronoun in the first person becomes toy (I). It is needless to state that this peculiarity adds considerably to the difficulties the student has to reckon with. During my search for an insight into the native tongue I came in contact with one of the native sergeants, known as Doy-Tho (doy— sergeant, and tho—a mountaineer). This non-commissioned officer belonged to the hardy and brave mountain tribes of Northern Tonquin, mention of which has already been made. He had distinguished himself on several occasions, and especially so during the operations against Hou-Thué in December and January. In appearance, and in his love of danger, he bore a strong resemblance to a Gurkah; and the following account of an incident which took place during one of the attacks on the rebel stronghold, related to me by a Legionary who was present, will give the reader some insight into the character of this plucky little soldier, and indeed into that of his fellow-tribesmen, of whom he was a good example. During one of the first engagements a section of the native regiment under the orders of a lieutenant succeeded in reaching the first palisade. From behind the trees, or lying flat on the ground, the men opened a smart fire on the rebel position, which was returned with vigour and punctuated by Oriental abuse, composed of rude remarks concerning the individual family of each tirailleur, and the graves of his ancestors.
- 42. Doy-Tho, maddened by these insults, stood up in full view of the enemy, and poured forth upon them a torrent of curses and invective. In their admiration of his daring, and their surprise at the volubility and scope of his abuse, most of the combatants forgot to fire, and a momentary lull took place in the engagement. It lasted a few seconds only, for, lashed to fury by the stinging retorts of the speaker, every rifle on that side of the rampart was turned upon him. His sakalo and cartridge-cases were shot away, and his clothes riddled with bullet holes; and it is probable that his body would have resembled a sieve had not his lieutenant sprung forward and dragged the howling mountaineer into safety behind a big tree. After this the rebels' fire slackened, and they shouted friendly invitations to the native troops to kill their officers and join them, saying that De-Nam would treat them well, and give one hundred dollars for every head of a French officer they would bring in. Tho replied with renewed invective from behind the tree, where he had been ordered to remain, and each pause, made through want of breath, he punctuated with a shot from his rifle. When the engagement was over, and the troops were retiring to Nha-Nam, the lieutenant aforementioned asked the little sergeant if he thought the promises of the rebels were bona fide ones. The nearest translation of Doy-Tho's reply in bad French was something after the following: "Hum! they belong big liars. Suppose I bring your head, mon lieutenant, perhaps I get ten dollars only." He and I soon became fast friends, and of an evening, before the door of the fort was closed, I would sometimes go for an hour to his caigna (native hut), and sit and talk with him whilst his wife prepared his evening meal of rice, dried fish, prawns and native salad. While we discussed the topics of the day, his sons—two sturdy, pot- bellied brats, aged respectively five and seven, naked as they were
- 43. born—would squat down on the floor of beaten clay and stare open- mouthed at me. His meal despatched, the little sergeant would stretch himself out on a clean rice straw mat placed on a platform-like bed made of split bamboo which covered half the room. His wife would then bring in a hardwood tray, whereon was a diminutive lamp, a bamboo opium pipe with a blue clay bowl, some little skewer-like implements of silver, and a tiny box of the same metal containing the daily ration of this seductive drug. Tho would lie on his right side, a hollow block of green-enamelled earthenware, serving as a pillow, beneath his head. His wife would stretch out opposite to and facing him. Between them was placed the tray with its little implements, and the lamp was lit. This was the solemn moment of the day. Tho reached out his skinny little brown hand and picked up his pipe, fondling it an instant prior to warming the bowl in the flames, his keen black eyes glancing over his favourite with the fond look of satisfaction and gratitude one sees on the face of a man who greets a well-beloved wife. This pipe, if such it can be called (for neither in bowl nor stem did it resemble the instrument we give that name to), was of similar form to that used by all Orientals who inhale opium fumes. It consisted of a stem, about 2 feet long, of polished bamboo, about 1½ inches in diameter, the lower end being closed by an ivory cap, while the other extremity was covered by a disc of silver with a small round hole in the centre of it. To this the lips were placed when the fumes were inhaled. About 6 inches from the lower end of the stem the bamboo was pierced to receive the neck of the bowl, shaped like a hollow, flat bulb. The top had a diameter of about 3 inches, and was well polished and slightly convex. In the middle was a tiny hole about as big as a pin's head.
- 44. It is, perhaps, as well to explain that no opium gets into the bowl, for it is consumed over the hole in the smooth convex surface on the top, owing to the air in the bulb having been inhaled and the consequent creation of a temporary vacuum. Thus only the fumes pass through the little orifice, up the stem and into the lungs of the smoker. Now Tho was warming his pipe over the flame of the lamp, withdrawing it now and again to gently polish the surface of the bulb upon the sleeve of his khaki jacket. His better-half dipped one of the little silver skewers into the tiny pot, and after turning it round drew it out covered with a coating of the rich brown drug, which looked like thick treacle. This she held over the flame for a second. It frizzled and gained in consistency; she withdrew it, and dipped it again into the drug, and it increased in volume. Three or four times this operation was repeated, until there was sufficient opium on the skewer to make a good pipe. The Doy now held his pipe to his mouth, and the tip of the flame licked the smooth, warm surface of the bowl on which his spouse began to roll the opium, holding the other end of the pipe in her left hand to steady it. Her dexterity was marvellous. In a few seconds the drug was detached from the skewer, and was rolled into a little ball about the size of a pea. She threw a glance at Tho which meant, "Are you ready?" He nodded, and started drawing at the bamboo. A gentle movement, and the skewer pushed the ball of opium on to the tiny hole, and it was held just over the lamp. There was a frizzle as the drug began to burn, continuing under the steady prolonged suction of the smoker. There was no smoke, for it was all going up the pipe into the little brown man's lungs. His eyes were half closed, and his features expressed a gentle beatitude, but his chest was swelling, swelling. Soon he could not continue the
- 45. steady suction, and he drew at the bamboo with a succession of quick, small pants. His wife, in the meanwhile, held the bowl well over the flame, and pushed up to the orifice the tiny particles of the drug still adhering to the convex surface. Presently all was consumed. I, on seeing this for the first time, sighed with relief, as one who had escaped from witnessing a catastrophe, when the smoker opened his mouth, and allowed the black smoke to escape slowly from between his lacquered teeth, which shone like ebony in the dim light of the tiny lamp. Tho watched the opaque column as it climbed slowly upwards to the bamboo cross-poles of his hut, and, forming into a little cloud, clung to the thatch of the roof. "Biet!" (good) he exclaimed, and then prepared for another. The air in the tiny room was now heavy with the odour of the drug, which at first seemed acrid and unpleasant, but it improved on acquaintance, and soon became soothing and enjoyable. The Doy liked to smoke his opium in peace, and, knowing this, I sat waiting until he should see fit to break the silence. Outside, the day was fast drawing to a close, and the short eastern sunset would in a few minutes be changed into night. From the Chinaman's shanty a few paces away came the sound of a rollicking ditty sung by some of my comrades over a pint of wine or a glass of absinthe. The noise seemed to wake all the cicalas in the neighbourhood, for they started at once a concert of chirping whistles. In the half-dried-up pools outside the village thousands of noisy members of the batrachian tribe broke into an endless chorus of complaint at the unwonted dryness of the season, while from time to time their big uncles, the bull-frogs, added a booming croak of approval. The matting hanging before the doorway of the hut swung back a little, moved by a hot breeze which brought to the nostrils a whiff of flowers and vegetation in decay; and I could see the fireflies already circling down the little street or about the thatch-covered caignas.
- 46. The heat was terrific, and seemed, if possible, less supportable now than it had done during the hours of blinding, scorching sunshine. All the earth seemed to radiate the caloric it had been stoking up during the day. When would the rains break? Those rains the other men who knew had told me of. Rains that chilled you to the bone, and made your teeth chatter. The thought that in the past—it seemed years ago—I had somewhere shivered with the cold, made me laugh aloud, as, after throwing off my light cotton jacket and rolling up my shirt-sleeves, I sat mopping the perspiration from my forehead. The veins of my neck seemed to swell, and my breath came in gasps. Thinking that it might be somewhat cooler there, I stepped into the street, and taking out my pouch, tried to roll a cigarette. Three times the thin paper broke in my sticky, perspiring fingers before I succeeded in obtaining a damp and flabby apology for a smoke. This slight exertion had caused me to perspire from every pore, and it seemed hotter outside than within. My light clothes clung to my limbs like those of a man pulled out of a pond. Disgusted, I returned and sat down again on the edge of the bed, and, after endless difficulty, succeeded in lighting my damp cigarette with a still damper match. The tiny twinkle of the opium-lamp deepened the darkness outside the small circle of its light. Tho's brownish-yellow features, on which it shone, reminded me of a quaint and clever old Japanese ivory I had once seen; and the dark background of the night was like the black velvet-lined case which had contained it. From where I sat I could see the arm of the sergeant's wife—bare from the elbow—and I watched with a kind of sleepy fascination her small and nimble fingers as they manipulated the drug. The soft light gave to her skin a rich gold tint, and made the arm and hand look graceful and comely. The Rembrandt-like effect of the picture gripped me, and for the moment the heat was forgotten.
- 47. Tho's voice brought me from a waking dream when, after laying down his pipe, he said: "Patience, camarade! It will come. When the bull-frogs join in the song the great waters are not far off. Were you on sentry to-night you would hear the dreary note of the rain-bird, for I'd stake a week's pay she will be out. Ba (his wife) tells me it sang to-day before sunrise; but women were ever dreamers." The little woman looked up from her task of cleaning the silver skewer, and retorted: "Dreamers! Oh, great slaughterer of men, and dost thou give me time to dream? Is not my life as full of work as our mountain rise is full of fat? Am I not still a tho from the Tam-Dao? (a group of mountains to the west of Thaï-Nguyen). Are not my teeth white, though I have a husband who has blackened his and become a plainsman?" As she smiled at her own wit I caught a flash of ivory between her red lips, and noticed for the first time the regularity of her small features. The Doy smiled good-naturedly, and replied: "Oh, thou silly one! Thou art pretty as an angry parrakeet, and talkest faster." Then to me: "Had I not lacquered my poor teeth— though my ancestors know the grief I suffered from it—how could I have gone, dressed like a pedlar, to spy in the villages for the Government? Had I tried so to do, the De-Nam would have eaten my liver long since. As it is, some day I shall probably eat his. Ba, get ready another pipe for me." "Nay! nay!" she answered, as she lit a small kerosine lamp of German make, and placed it on the bed; "thou hast eaten ten times of the drug, and it is thy just ration." She blew out the small light and carried away the tray, saying to me as she did so: "Were I to listen to this man he would turn all the Government dollars he gets into black smoke, and I and my sons would have to go in shame to my father and beg for food."
- 48. It was very evident that Madame Ba ruled the roost, and it was probably better so. Tho growled a little, and protested to me: "Was ever man burdened with such a wife? She has no respect for me—the senior sergeant in the company. Now, had I married——" Here he was interrupted by the first notes of the bugle calling us back to the fort, and we rose together and hurried out of the hut. It was quite dark outside. Tho did not speak until we had nearly reached the gate, then he said: "Camarade, when the time comes, I hope you will find for yourself a white woman with a heart like Ba's. Bonne nuit!" And he ran off to his section. Lying on my bed that night I communicated to my neighbour, Lipthay, a Hungarian, the incidents of the evening, and together we laughed over the recital of little Tho's domestic worries. This room- mate of mine had come out with our detachment on the Bien-Hoa. On our arrival at Nha-Nam we had been given beds next each other, and our acquaintance was fast ripening into a close friendship. Lipthay had joined in April of the preceding year. Shortly before this he held a commission in the Austrian army, which he had resigned. A braver, more loyal and upright nature I have never met. I have never learnt the reasons which brought him into the Legion, but am convinced they were honourable, for during the four years we were almost continually together his speech and conduct were always those of a gentleman in the truest sense of the word. He was an adept at military topography, and, to while away the time, would give me further lessons in this useful art, of which I had already some slight knowledge. This having reached the ears of our Captain, we accompanied in turns the occasional reconnoitring parties, and made topos of the route taken. His work was of the first quality, and his draughtsmanship of a very high order. The following morning I came across Tho, who was conducting the sick men of his detachment to the doctor. He halted an instant to ask
- 49. me if I was coming to see him that evening, and I told him I should be deprived of that pleasure, as my section was on picquet duty at 5 p.m. At this he grinned, and said: "Well, then, we shall meet later, for there will be some fun to-night." He then left me, and trotted off to rejoin his men. I knew it was no good trying to obtain further information from him, for the Doy was like the majority of Orientals, from whom torture will not wring a secret they have decided to keep, so I did not attempt to see him again that day. However, as I knew that he served as interpreter to our commander when spies were interrogated, I inferred from the hint he had given me that some movement was to be made that night. My section assembled, and were inspected with the guard that evening, and afterwards we were dismissed, but had to remain dressed and armed in our room in the event of our services being required. I took Lipthay into my confidence, and told him of the "tip" I had received. I induced him to do as I did, and fill his water-bottle with cold coffee in case of necessity. Fully dressed, with our belt and cartridge-cases on, we lay down on our cots to snatch a few hours' rest. At 1 a.m. our squad corporal shook us out of our slumbers, and, together with the other men of our section, we snatched up our rifles and assembled outside as quietly as possible. Here we found a half-section of native troops under the orders of Tho, who nodded to me and grinned as I stepped up and took my place in the ranks. Two hard-boiled eggs and a slice of bread were served out to each man, which we were told to put in our wallet for future use. A few minutes later Captain Plessier came upon the scene, and noticing that he was not mounted, I surmised that our coming peregrinations were to take place over difficult ground.
- 50. So indeed it proved, for, after the gate had been opened by the sentry, our little column went out in silence, like a troop of ghosts, in Indian file, turned to the right, and proceeded to the south-west across the paddy fields by the narrow ridges which served as paths. The night was stifling and pitch-dark—so dark, indeed, that each man had to hold on to the wallet of his comrade in front so as not to lose his way. Thus progress was very slow. When we had been walking about an hour, and had covered, perhaps, a mile and a half, the blackness of the night was of a sudden lit up by a brilliant flash of lightning which illuminated, for the fraction of a second, the surrounding country. The weird aspect of it, with the tall outlines of the palms and bamboo silhouetted against the sky, remained with a strange vividness as if photographed upon the retina, for several minutes. This was succeeded by a peal of thunder so deafening that it seemed to split the ear-drums and shake the ground beneath us, and the rain came down as it only can do in the tropics. For a few seconds our little troop was thrown into confusion, and some of the men, temporarily blinded by the sudden light, stepped into the fields, where they floundered about with water and mud almost up to their knees. After this interruption we proceeded on our way. Very slowly though, for the lightning continued, flash following flash, in quick succession for an hour, and our ears were weary with the crashing of the thunder. The track, which was of clay, was sodden and slippery. We were all wet through to the skin, and our boots, full of water, emitted a curious squashing noise at each step. Fortunately the din of the thunder and the continued thresh of the rain more than covered the noisy advance of our column. Ten minutes before, wet through with perspiration, I had mentally cursed the heat; now my teeth were chattering and my fingers were numbed with the cold. I felt a strange joy at it, smiled to myself at the evident truth of Tho's recent prophecy anent the "great waters," and thought how appropriate was his term for the downpour.
- 51. For two hours we continued on our slippery way, and were then halted on a patch of grass covered with little mounds—a village graveyard. Here our expedition was broken up into little parties, the one to which I belonged being composed of ten Legionaries and a sergeant, and as many tirailleurs, with Tho at their head. We proceeded a short distance, and were ordered to be down in some long grass, behind a clump of cactus and hibiscus shrubs. As we did so, I heard the Doy say to our sergeant: "When it will be light we shall see the door of the village from here; the path to it is a little to our left." From this, and the movements I could hear on our right and left, I gathered that the remainder of the column was surrounding a village which lay before us, but owing to the darkness and the rain I could distinguish nothing ahead of me. We had been lying on the ground some minutes, and, notwithstanding the chill dampness, I was almost falling into a doze, for the walk had tired me, when from the surrounding darkness a figure came noiselessly and crouched beside me. The next instant Tho's voice whispered in my ear: "I told you so; it has come." "Yes"—I shivered—"and I think I have had enough of it." "No! say not so! A few more hours and you will grumble at the heat once more, camarade! 'Tis a fool who ever complains. Our land had sore need of the rain; the crops will drink this as the mandarin does his Yunan tea. When the sun rises all the earth will rejoice. The voice of the tempest has shut the ears of our enemy to the noisy approach of the linhtap lanxa (European soldier). This time we shall surely surprise the brigands; therefore we should thank our Lord Bhouddah for his great mercy." "What village is before us, friend?"
- 52. "Yen-Trieu," he answered; "and in it is a linh-binh (sergeant) of the De-Nam with twenty men. They are collecting the taxes, and were to have left it this morning. But they will never leave it," he added, with a low chuckle. "Yesterday the spies came and told the Captain. I was there. Last night they surely feasted, drank much choum-choum (rice alcohol), and smoked many pipes, for the headman is a great traitor, and in secret a partisan of Ham-Nghi." "We shall have much trouble to enter," I ventured, "for we have not brought axes." Tho chuckled again, and said: "Let not that trouble thee. I have advised the Ong-quang-Ba (the Captain—literally, 'Lord of three stripes'), and these fools will open the door themselves; even as I said to him." I turned to chide him for his presumption, but he had glided away silently into the night. The rain had ceased now almost as suddenly as it had commenced, and the smell of the damp earth and vegetation reeked in the nostrils. Turning, I glanced behind me, and saw that towards the east the sky was grey. In a few minutes the forms of my comrades near by could be dimly distinguished. The nearest—he was barely a yard away—was a boy of twenty, an Alsatian. He was fast asleep, his head pillowed on his arm, and dreaming pleasantly, for on his lips, which bore no trace of a moustache, I could discern a smile. Fearing lest the sergeant should find him thus, I awoke him, and he thanked me. It was now so light that a few paces away to the left I recognised our Captain, seated on the ground. He was chewing the end of an unlit cigar. In a low voice he called the sergeant, and talked for some moments to him. Then our "non-com" came from one to the other of us and communicated the instructions he had just received. These were:
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