WOUNDS. 



per/ahum, like that of all wounded arteries, and it gufties 

 out both in infpiration and expiration, but without any 

 hiffing noife, and not blended with mucus and air, like 

 the blood which is difcharged from a deep wound of the 

 ungs. 



We fhould not have expefted much hemorrhage from the 

 intercoftal artery when wounded by a ball, much lefs Ihouid 

 ■we have expefted that it was ever poffible to take up that 

 veffel with a tenaculum. Yet a late writer obferves, " when- 

 ever the tenaculum can be ufed to an intercoftal artery 

 injured by a ball, it (hould at once be applied, and the veffel 

 fecured by ligature." (See Hennen's Obf. on Military 

 Surgery, p. 401.) Profeffor Thomfon heard only of one 

 hemorrhage from the intercoftal artery after a gun-fliot 

 wound received at Waterloo, and this was a fecondary bleed- 

 ing on the fifteenth day. It was flopped by a comprefs. 

 See Obf. on the Military Hofpitals, &c. p. 83. 



This fort of bleeding can only be ftoppedby compreflion, 

 and in order that the plan may be effeftually praftifed, it 

 is fometimes neceffary to enlarge the wound by an incifion. 

 When the finger is put under the wounded artery the bleed- 

 ing ceafes, which obvioufly proves that there is no occafion 

 ■for needles, nor for any particular inventions for flopping 

 the hemorrhage. According to M. Laffus, it will be quite 

 enough to introduce between the ribs a tent, or doflil of 

 charpie, which is to be kept in the wound four or five days. 

 The bleeding having flopped, the wound will difcharge for 

 fome days a reddilli purulent fluid, and if the lung be not 

 perceptibly injured, the cure will be fpeedily effefted by 

 ordinary treatment. 



The method which has been tried for flopping hemor- 

 rhage from a wound of the internal mammary artery is 

 analogous to the foregoing. A man was flabbed with a 

 fword, which entered obliquely between the cartilages of the 

 ribs. The wound was not extenfive ; but the clfufion of 

 blood in the cellular membrane of the lateral and anterior 

 part of the thorax was confiderable. An incifion was made 

 in the integuments covering the mafs of blood, and feveral 

 coagula were removed. The hemorrhage was then flopped 

 by introducing fome agaric, which was faflened to a fpatula, 

 and by means of this inftrument, preffed from within out- 

 ward, under the cartilage of the rib, near the fide of the 

 flernum. The wounded artery was thus very exaftly com- 

 preffed, and the plan was continued feveral days and nights 

 fucceffively under the diredlion of a furgeon. Laffus, Pathol. 

 Chir. torn. ii. p. 312. 



■ An extravafation of a confiderable quantity of blood in 

 ■one of the cavities of the pleura is followed by fuch a train 

 of alarming and urgent fymptoms, tliat the patient dies 

 :of fuffocation unlefs the fluid be difcharged. This may 

 be accomplifhed either by making the patient lie on his 

 wounded fide, if the wound can thus be made depending, 

 and it be fufSciently ample, or enlarging it with a bifloury, 

 when it is too narrow, or by making another opening in the 

 thorax when the wound is fituated too high up. ( See Em- 

 PYEiMA.) If the hemorrhage ftill continue, and be con- 

 fiderable, after the firfl extravafated blood has been dif- 

 charged, the patient generally perifl.ej ; but when the bleed- 

 ing ceafes, and the lungs are not extenfively injured, he may 

 recover. Nothing but the urgency of the fymptoms of fuf- 

 focation, arifing from a dangerous degree of preffure upon 

 the lungs and diaphragm, can jullify a hafty determination 

 to make an opening for the evacuation of the extravafated 

 blood, or the equally pernicious plan of leaving the original 

 v/ound open for the fame purpofe. If the furgeon require 

 arguments in fupport of this remark, they are to be derived 

 from the equivocal, uuceruiii; and irregular character of the 



fymptoms of an extravafation of blood in the thorax, and 

 from the effed which even the difcharge of fuch blood may 

 have in renewing the hemorrhage, and making room for 

 another efFufion, in cafes where the injured veflels are large. 

 The blood, however, mufl be difcharged when the fymp- 

 toms of fuffocation are urgent, and evidently owing to the 

 preffure of the extravafation on the organs of refpiration. 

 The praftice of making an opening will always be unfuc- 

 cefsful, when the wound of the lungs, befides being deep 

 enough to give rife to an extravafation,is alfo complicated with 

 emphyfema of thofe organs, and the effufion of a confider- 

 able quantity of blood into their cellular and parenchymatous 

 texture. In ftiort, in a wound of this ferious defcription, it 

 does not conftantly happen, that the only curative indication 

 is to difcharge the extravafated blood. The degree of danger 

 depends upon the nature of the wound of the lungs, which 

 is invifible, and of which it is fometimes difficult to form a 

 correift judgment. Frequently an extravafation of blood in 

 the pericardium, without injury of the heart, but a cafe 

 which is always fatal, has been miflaken for an extravafation 

 in the cavity of the left pleura. Sometimes, alfo, we may 

 be deceived, and believe in the exiftence of an extravafation, 

 while the fymptoms of fuffocation under which the patient 

 labours may be owing to the fubflance of the lungs being 

 changed as it were into a folid mafs, by the effufion of blood 

 and coagulating lymph in their texture, and the confequent 

 compreffion of the air-cells. 



Although it mufl be acknowledged, that the diagnofis of 

 an extravafation of blood in the cheft is not free from diffi- 

 culties, the following are ufually regarded as the fymptoms 

 which charafterize the cafe, either in the primary or fecond- 

 ary form. In the firfl place it is obvious, that there mufl 

 generally be a wound of the lungs, which is indicated by the 

 iffue of frothy blood from the wound, by the paffage of 

 air through the wound into and out of the cheil, and by 

 the patient fpitting blood, or coughing it up in large quan- 

 tities. If, however, the blood come from the intercoftal 

 artery, no blood will be coughed up. At the moment of 

 receiving the wound, the palient falls into a flateof fyncope, 

 and though the bleeding may not be very confiderable, he is 

 affefted with cold fweats, and his pulfe is feeble and fmall. 

 In the courfe of a few days, notwithflanding a low diet, 

 repeated bleedings, and perfeft quietude, refpiration be- 

 comes fhort, difficult, and laborious, and infpiration is ob- 

 ferved to be performed more eafily than expiration. The 

 patient ufually lies upon the fide in which the extravafation 

 IS ; and this fide feems rather larger and broader at its lower 

 part than the oppofite fide, on which the patient cannot lie 

 without an aggravation of all his fufferings. When he tries 

 to fit up in bed, he cannot remain in this pofition, unlefs he 

 bends his body very much forwards, in order to facilitate 

 refpiration. About the xiphoid cartilage and the lateral 

 parts of the cheft, he feels a weight, attended with a frequent 

 cough, and a fenfation of fuffocation. According to Va- 

 lentin, a large ecchymofis, or violet-coloured fpot, makes its 

 appearance in fome individuals in a later flage of the cafe 

 about the angles of the falfe ribs ; but this fymptom is far 

 from being conftant, and it did not occur in an inftance 

 of extravafation of blood in the thorax recorded by Dr. 

 Thomfon. ( Reports of Obfervations made in the Military 

 Hofpitals in Belgium, p. 85. ) In general, blood efcapes 

 from the wound, unlefs the opening be very fmall, or fitu- 

 ated in the upper part of the chefl. Laftly, it is remarked, 

 that the fymptoms of fuffocation proceeding from inflam- 

 mation of the lungs fubfide, or are evidently leffened by 

 venefedlion, whicli is not the cafe when they depend upon 

 an extravafation. 



If 



