WOUNDS. 



trachea, deluges the hings ; the patient fpits up a frothy 



i blood ; blood, inftead of air, occupies the bronchiae ; fo 



: that he ftruggles for breath but a few moments, and then 



expires." John Bell's Difcourfe on the Nature and Cure 



of Wounds, p. 257. edit. 3. 



We Ihall next confider the treatment of penetrating 

 wounds of the cheft. In thefe cafes, the patient may die 

 inftantaneoufly of internal hemorrhage and-futfocation ; or 

 he may be cut off by the effefts of inflammation within 

 the cavity of the thorax. If ( fays Mr. John Bell ) the pa- 

 tient be fpitting blood and breathing high, but not much 

 oppreffed, or his oppreffion increaling very flowly, there are 

 hopes that he may be faved. If there be no great veflel 

 wounded in the lungs fo as to fuffocate him at once, it is 

 probable that the fmaller vefTels which are opened by the 

 wound will gradually ceafe to bleed ; and after four or five 

 days of alarming cough, with bloody expeftoration, that 

 fymptom will ceafe ; and in order that he may the fooner be 

 relieved from his danger, he miijl be bled very freely. Let it 

 be the intention to reduce him very low by quick bleedings ; 

 and let thefe bleedings (fays Mr. John Bell) have the 

 \ effeft of continued internal hemorrhage, without the dangers 

 of it. Let them deprefs him to the fame low condition to 

 which the inward bleeding would moft likely have brought 

 him ; and the fyftem being emptied in this direftion, there 

 will be lefs danger of immediate fuffocation in the lungs, 

 and but little fear of the fucceeding inflammation rifing too 

 j high. It is only by thefe repeated bleedings that the pa- 

 ! tient can be faved : the vafcular fyftem muft be kept low 

 i in aftion, and fo drained as to prevent the lungs from being 

 1 opprrfTed with blood. 



One thing (continues the fame author) is very clear, that 

 ; if the furgeon bleed only when the cough and bleeding 

 [ from the lungs return, he never can do wrong. The 

 patient, lying ftruggling before him, is to lofe a given quan- 

 tity of blood ; if it be allowed to flow out into the lungs 

 he may be fuffocated ; if it be drawn from the arm, this 

 fuffocation is prevented. If he be kept low enough by 

 bleeding, there will be no blood to fpare for this extrava- 

 fation into the lungs, &c. (Op. cit. p. 259, 260.) We 

 repeat, in all cafes of penetrating wounds of the cheft, and 

 efpecially in injuries of the lungs, the free ufe of the lancet 

 is the only thing which can be depended upon in the early 

 part of the treatment. By it, internal hemorrhage is re- 

 ftrained ; and by it, the dangers of the fubfequent inflam- 

 mation of the thoracic vifcera are to be averted. The re- 

 cords of furgery furnifh abundant proof of the neceffity of 

 fuch praftice, and the extent to v/hich the bleeding muft be 

 carried is fometimes furprifing. Thus, in a cafe in which 

 a mufl<et-ball had entered the left (houlder, pafTed through 

 the lungs, and come out below the left nipple, a profufe 

 hemorrhage of arterial blood took place from the mouth, 

 and threatened immediate fuffocation. This hemorrhage 

 was checked by repeated bleedings, which were reforted to 

 on every frelh attack of the hemorrhage, and pufhed till 

 relief was obtained. Leeches were applied to the fide in 

 great numbers, and the antiphlogiftic plan of treatment was 

 ftriftly purfued. Two hundred and fifty ounces of blood 

 were in this cafe drawn off hy the lancet in eighteen days. 

 (See Thomfon's Reports of Obf made in the Military 

 Hofpitals in Belgmm, p. 86. ) In every inftance of a pene- 

 trating wound of the cheft, and more particularly when the 

 lungs are injured, the fu-!t bleeding fhould be copious. As 

 Mr. Henneu recommends, from thirty to forty ounces of 

 blood fhould be taken from the arm by a large orifice. If the 

 patient fhould faint, we ought not to adminifter cordials to 

 him, but allow him to revive gradually. We fhould avail 



ourfelves of this opportunity of cxtrafling without pain all 

 foreign bodies within reach, whether cloth, ball, iron, wood, 

 fplinters of bone, &c. Should there be reafon to think 

 that iuch extraneous fubftances are lodged, and that by an 

 enlargement of the orifice of the wound they might be ex- 

 tracted, the praftice ought to be immediately adopted. 



The next objeft is to drefs the wound itfelf. " If it is 

 a gun-fhot (fays Mr. Henncn ), a light mild dreffing will be 

 fufRcient ; but if incifed, the lips of it fhould be clofed at 

 once, and this treatment will be found to afford the moft 

 certain preventive to emphyfema (fee Emphysema), future 

 hemorrhage, and colleftions of matter. ( See Empyema. ) 

 I fcarcely recollect an inftance where it was neceffary to 

 remove the adhefive ftraps, or (where it was a gun-fhot) the 

 ufual dreffings. We now lay the man down, and let him 

 remain as quiet as pofiible, and in as cool and airy a fpot of 

 the barn, church, or hofpital, as we can find. He will often 

 require no farther aid ; but if the cafe is very fevere, he 

 will probably lie for fome hours in a ftate of comparative 

 eafe, till the veffels again pour forth their contents, and 

 induce frefh fpitting of bloody froth, and a repetition of all 

 the fymptoms of approaching fuffocation. The lancet muft 

 again be had recourfe to ; and if by this management, re- 

 peated as often as circumftances demand, the patient fur- 

 vives the firft twelve hours, hopes may begin to be en- 

 tertained of his recovering from the immediate effefts of 

 hemorrhage. In the after-treatment of a wound of the 

 nature here defcribed, we (hall be confiderably affifted by 

 the aid of medicine ; but until the danger of immediate 

 death from hemorrhage is over, we muft not think of em- 

 ploying any thing except depletion by the lancet : it, and it 

 only, can fave the life of the wounded man." Hennen's 

 Obf. on Military Surgery, p. 398. 



When the paroxyfms of pain, the fenfe of fuffocation, 

 and return of hemorrhage, fays Mr. Hennen, have become 

 more moderate, and recur at longer intervals, we may have 

 recourfe to means of lefs immediate influence, and fpare the 

 lancet. In this view, the moft powerful medicine that we 

 can adminifter is the different preparations of digitalis, in 

 fuch form as may beft agree with the patient ; and if the 

 pain and efforts to cough are fevere and fpafmodic, we muft 

 have recourfe to the aid of opiates. To this courfe of 

 medicine (hould be added a rigour of diet, amounting to the 

 total prohibition of every thing fohd, and admitting of 

 fluids only of the mildeft nature and leaft irritating quality ; 

 and even thofe in fmall quantities, and duly acidulated. 

 Should we be fortunate enough to preferve our patient 

 during the firft fix or feven days, a relaxation in this rigour 

 may be cautioufly admitted ; but a departure from the 

 general plan, or an omiffion of bleeding on the rifing of the 

 fymptoms, can only tend to accelerate the event that our 

 efforts are defigned to counteraft. Mild faline purges, and 

 an emollient enema, fhould be occafionally adminiilered if 

 required, and the patient kept in a ftate of the utmoft quiet 

 and feclufion from all external impreffions, and in a cool 

 atmofphere. (Op. cit. p.400. ) The plan of exciting a 

 counter-irritation on the furface of the cheft, by means of 

 bhfters, fhould alfo never be omitted, when much cough 

 and pain in the breaft continue after bleeding has been fully 

 praftifed. In fome examples, the inflammation occafioned 

 by penetrating wounds of the cheft terminates in fuppura- 

 tion within the lungs, or the fac of the pleura. The fymp- 

 toms, however, which indicate fuch an occurrence, and the 

 mode of treatment, are fo amply explained in another part of 

 this work (fee Empyema), that we (hall not enter into the 

 fubjeft again. 



There is one circumftance which lometimes deceives the 



furgeon, 



