WOUNDS. 



If it be true that forae patients have had their breath- 

 ing very little opprefTed, notwithftanding an extravafation 

 of blood in one of the cavities of the pleura, and that others 

 have been able to lie with equal eafe either on the found or 

 difeafed iide ( fee Thomfon's Report, p. 87.). which is not 

 common, we mull conclude from thefe unufual cafes, that 

 we ought not to form our opinion from any one fymptora 

 in particular, but from the aflemblage of a great many. 

 LafTus, Pathol. Chir. tom. ii. p. 319. 



On the fubjedl of extravafations of blood in the thorax, 

 the following are the fentiments of a dillinguifhed writer : 

 " Whatever may be the caufe of this inward bleeding, the 

 furgeon (hould attend to the following diredlions. He (hould 

 firft put his finger into the wound ; perhaps it may difcover 

 the caufe, or may evacuate the blood. If the blood do 

 not follow the finger, then fome tube mult be introduced, 

 and the tube for fo fimple an operation need not be a nice 

 one. If he cannot get the tube into the thorax, and the 

 breathing continue opprefled, he muft enlarge the wound, 

 and enlarge it freely. To be afraid of expofmg the lungs 

 to air when they are already torn with a bullet and loaded 

 with blood is childifh and ufelefs theory, vei7 unlike the 

 proper management of fuch wounds. If the wound in the 

 thorax be not too high above the third or fourth rib, and 

 if no pofture of the patient, however willing or able to turn 

 himfelf, will bring the blood eafily in that way, or if the 

 wound be contufed, obhque, and difficult to dilate, an 

 operation mult be performed, which, as it is commonly prac- 

 tifed for pus in the breaft, is called the operation of Em- 

 pyema (fee this word) ; that is, a very free incifion muft be 

 made in the line betwixt two of the ribs ; then the pleura 

 muft be punftured with a lancet, and a tube introduced. 

 Or, in plain language, whenever it is found that the natural 

 wound will not empty the thorax, a new wound Ihould be 

 made in what is called the chofen point, or the point of 

 cleclion, ;'. e. low, betwixt the feventh and eighth ribs, that 

 there may be an eafy flow. But whenever the wound is 

 about the middle of the thorax, it ftiould rather be dilated, 

 which both changes the nature of the wound and gets out 

 the blood. When this blood proceeds from a wound of the 

 intercoftal artery, fuch free inciiions are the more neceffary ; 

 they allow us to fee the artery, to feel the jet of its warm 

 blood by putting in the finger, and this allows us to prefs 

 it with a comprels, or tie it with the needle and thread." 

 (See John Bell's Difcourfes on Wounds, p. 263, 264. edit. 3. ) 

 However, notwithftanding this author, and a few other fur- 

 geons thus talk of taking up the intercoftal artery, we 

 much doubt the polTibility of the thing, nor do we know of 

 any well-authenticated cafe on record where it has aftually 

 been done. 



The propriety of fome^other parts of this advice is alfo 

 queftionable, efpecially that relating to thrufting tubes into 

 the cavity of the thorax. The neceffity of cutting into the 

 chelt at aU in order to let out extravafated blood, in an early 

 ftage of a wound of the thorax, is pofitively denied by 

 Scarpa, as we (hall find from an extraft we ihall have to 

 make from his work in fpeaking of wounds of the belly. 

 On the contrary, Scarpa, Larrey, Affalini, Hennen, &c. 

 all agree, that wounds of the cheft ftiould be clofed, and 

 fuperficially and lightly drefied. At all events, we may 

 fafely affert, that in thefe cafes nothing but the urgency of 

 the danger, unequivocally arifing from the prefl"ure of the 

 mafs of extravafated blood on the organs of refpiration, can 

 ever juftify the practice of either making another opening 

 into the cheft, or of enlarging the original one. Of the 

 method of keeping the wound open with tubes or tents, we 

 have a very unfavourable opinion. 



In every cafe of extravafation of blood in the cheft, the 

 difcharge of it when refpiration is dangeroufly oppreiTed is 

 not the only indication. There is another one of at leaft 

 equal importance : we allude to the adoption of a rigorous 

 antiphlogiftic treatment, in order to avert and diminifh 

 the dangers arifing from inflammation of the pleura and 

 lungs. 



Befides extravafation of blood in the cavity of the pleura, 

 there is another complication which fometimes attends 

 wounds of the cheft, and is particularly deferving of the 

 attention of tl)e praftitioner. We mean the cafe of emphy- 

 fema, or what Mr. John Bell calls " the tumour formed by 

 air blown out from the lungs into the common cellular fub- 

 ftance, or confined within the thorax, and oppreffing the 

 lungs." It is not, however, our wifti to detain the reader 

 long on this interefting diforder, becaufe by turning to the 

 article Emphysema, he will find a ftatement of all the prin- 

 cipal knowledge which exiils upon the fubjeft. 



Emphyfema arifes from the air efcaping, firft from the 

 lungs into the thorax ; then from the thorax through the 

 wound in the pleura coftalis into the cellular fubftance on 

 the outfide of the cheft ; and afterwards, the air inflates the 

 cellular membrane over the whole body. As Mr. John Bell 

 has related, emphyfema is frequent after a fraclured rib, 

 becaufe there is a wide laceration of the lungs, and no exit 

 for the air ; while it is lefs frequent in large wounds with a 

 knife or broad-fword, becaufe in fuch cafes the air has an 

 open and unimpeded iflue. It is very common after deep 

 itabs with the bayonet or fmall-fword ; and it fometimes 

 arifes in gun-fliot wounds, though, as far as our experience 

 extends, it is not fo frequent in thefe particular inftances, as 

 Mr. John Bell defcribes. Mr. Hennen thinks it does not 

 occur in more than one cafe out of fifty (p. 402.), which 

 is, perhaps, a calculation confiderably below the real ftate 

 of things. 



When the lungs are wounded, the air efcapes from them 

 at every infpiration into the cavity of the pleura, whence 

 the next expiration it is comprefled, and forced through the 

 breach of continuity in the pleura into the cellular fubftance 

 on the outfide of the cheft ; for it ' .uinot return into the 

 wounded lung, becaufe this is already full. Every new in- 

 fpiration draws more air from the wounded lung, and every 

 new expiration drives more air but into the cellular fub- 

 ftance. There is no other outlet for the air, which fpreads 

 under the fliin with wonderful rapidity. Theemphyfematous 

 crackling tumour makes its firft appearance over the broken 

 rib, or over the wounded point of the thorax ; it then ex- 

 tends over the whole cheft, and next over the neck and 

 face, filling particularly the eye-lids, fo that the eyes are 

 abfolutely clofed. It afterwards extends icfelf over the 

 belly, down the thighs, and to the private pans, and no part 

 efcapes this tumour, except the paims of the hands and the 

 foles of the feet. More air is every moment drawn out 

 from the wound of the lungs, and driven under the Ikin ; 

 and the patient is every moment more and more opprefTed, till 

 at laft the breathing is quite interrupted, the pulfe flags, the 

 extremities grow cold, and the patient, if he be not reheved 

 by fome operation, muft die. John Bell, p. 267, 26R. 



The moment that the lungs are wounded, (fays this 

 author, ) they fall down, and continue in this collapfed ftate 

 until the wound heals, which it does in the courfe of a very 

 few days ; but from the moment in which lungs are wounded, 

 the ufe of the wounded lobe is loft, fo that if the wound be 

 in the right fide of the lungs, the breathing is performed 

 entirely by the left ; only half the quantity of air is infpired, 

 and the breathing is difficult. 



If the lungs, when wounded, were to continue in perpe- 

 tual 



