SURGERY. 
739 
2d. “ Tf this nervous commotion being 
quieted, a sharp fever should come on, still 
do not bleed, but rather be upon the reserve; 
for perhaps this, which at first seems to be a 
pure inflammatory fever, may turn out to 
be a fit of an ague, to which the patient is 
subject ; it may be a low and malignant 
fever ; it may be an attack or' some camp 
disease ; and if a diarrhoea, great weakness, 
and low muttering delirium, should come on 
immediately alter you have bled your patient 
freely, you would be distressed at the 
thought of what you had done, and you would 
indeed have much to answer for. 
3d. “ Reserve your bleedings for those 
more dangerous cases, where high inflamma- 
tion is so often fatal, and do not bleed in 
wounds of the hips, shoulders, or limbs. Re- 
serve bleeding for wounds of the breast or 
belly, or great joints; for in all wounds of 
cavities, inflammation, which can hardly be 
escaped, is the great danger. 
4th. “ If a man is wounded after a full 
meal, there can be no doubt that a gentle 
vomiting must be useful, where it is allowed 
by the circumstances of the wound. The old 
physicians found their advantage in it, and 
ascribed the good effects of vomiting to the 
preventing of crude and ill-concocted chyle 
from entering into the system, so as to kindle 
up a fever. 'There is no doubt that a meal 
which was no load during health, will be a great 
oppression upon a disordered system, and 
the carrying it off must be a great relief, al- 
though the old physicians, by talking this use- 
less jargon about ill-concocted chyle, might 
almost provoke us to reject both the doctrine 
and the practice. The system cannot be 
weakened by a gentle emetic; and if the 
system should fall low after vomiting, it were 
easy to substitute a litter support, and better 
excitement, than that of an oppressed stomach 
and loaded intestines, by first discharging 
these crude meats, and giving, when the sto- 
mach was emptied, food of easy digestion, 
and cordials suited to the condition ol the 
system. 
" 5th. “ But in every wound there comes a 
period of weakness, in which we repent of 
every bleeding we have made, even when it 
was really needed; a period in which, by 
confinement and pain, occasional fever, 
diarrhoea, profuse suppuration, or colliqua- 
tive sweats, the patient falls so low that it is 
not easy to support him through the cure: 
and thus there are two great principles in the 
treatment of gun-shot wounds : that even 
at first we should be sparing of blood ; and 
that the period of weakness which is to suc- 
ceed, is the great danger ; on this single point 
hangs all the practice.” 
The author afterwards adds, that in mere 
flesh-wounds we are not entitled to bleed; 
for if there is no wound of a joint, or frac- 
tured bone, the first inflammation never runs 
too flight. 
By due attention to the above rules, the 
surgeon will never find himself at a loss with 
regard to the immediate requisitions of the 
wounded, either in army, navy, hospital, or 
private practice. It will scarcely be neces- 
sary to observe, that where immediate bleed- 
ing' is judged necessary (and this is always 
the case, as above stated, in wounds of ca- 
vities and joints), it may be employed most 
freely in the young, full-fed, vigorous, and 
plethoric, in dry and healthy situations, in 
the spring of the year, when no epidemic dis- 
order prevails, and when the patient is after- 
wards to enjoy all the advantages of cleanli- 
ness, air, and a suitable diet. 
In the progress of the cure, the surgeon 
is still not for a moment to lose sight ot the 
intimate connection between the condition 
of the general system, and the state of the 
wound. Still fever is to be distinguished 
from inflammation : and the tup opposite kinds 
of inflammation treated of in the article 
Medicine, vol. ii. p. 250, are likewise to be 
sedulously discriminated : the one will re- 
quire a low diet, evacuating medicines, and, 
as it is expressed, a cooling antiphlogistic 
regimen ; the other as loudly calls for bark, 
wine, opium, elixir of vitriol, and above all 
pure air, and (so as not to overload or op- 
press the weakened organs of digestion), rich 
or rather nourishing food. Here, instead ol 
further reducing the system, “ you must 
trust to air and cleanliness, and bark and 
wine.” 
We now proceed to speak of the treatment 
of wounds in the two cavities of the chest and 
belly. 
The first and great danger in a wound 
which has penetrated the thoracic cavity, is 
that of suffocation from blood poured into the 
air-cells, or towards the trachea. The first 
and principal object then of the surgeon is to 
obviate this consequence as speedily as pos- 
sible ; and here immediate and oftentimes 
frequently-repeated bleedings are called for, 
even should the patient be in a condition un- 
favourable to the discharge of blood. “ Here 
it is your duty to keep the patient low, and to 
drain his system so thoroughly of blood, that 
none shall pass towards the lungs to suffocate 
him, and that there may not be blood enough 
in the system to serve as fuel for that inflam- 
mation which sooner or later must come on.” 
When the blood is merely poured into the 
cellular membrane or cavity of the breast, 
without entering the air-cells, the finger, as 
already mentioned, is to be introduced into 
the wound ; or if this wound is too high for 
the necessary discharge of the extravasaled 
blood, a fresh wound may be made lower 
down upon the breast, and this so that the 
surgeon may have it in his power to reach 
and tie the intercostal artery, if this artery 
has be^D divided. 
For the emphysema or windy swelling, 
which is often so alarming to the by- 
standers, but which is in reality the most 
trivial symptom, scarifications are to be 
made in order to discharge the collected air. 
If, during the cure of a breast-wound, there 
comes on a pricking in the side ; if the cough 
is aggravated, the discharge becomes more 
copious, and the systematic irritation in- 
creased, there will be reason to suspect the 
remains of some irritating material, as a 
splinter of bone ; in this case, the wound is 
to be probed, injected, and every endeavour 
made to extract the irritating cause. 
“ Sensible, at every turn, now-slight a mat- 
ter will irritate the pleura and lungs, the 
surgeon w ill never allow himself to do so un- 
natural and cruel a thing as to pass a great 
cord across the chest, which is thus easily 
irritated by the most trifling piece of bone or 
rag of cloth; but he merely lays a bit of 
piled caddis gently within the wound, with a 
large emollient poultice over all.” 
To conclude. In the wounds we are now 
describing, the surgeon must in the first day 
bleed copiously, and repeatedly ; he must 
again bleed should bloody expectoration re- 
cur, weakening the systeni in order to pre- 1 
vent suffocation ; “ and when the time comes 
in which the oppression is forgotten, and the j 
danger of suffocation, and the bleedings from a 
the lungs, are over, he begins to support his | 
patient’s strength with opium and bark, aadrJI 
nourishing diet and milk.” 
Wounds in the abdomen. While the dangeri 
from wounded lungs is chiefly of suffocation,! 
in wounds of the abdomen, as before stated,! 
we have principally to fear either sudden! 
death from internal hemorrhage, or peritonaea!! 
inflammation, when the bleeding has not been! 
so profuse. Against this internal bleed&gj I 
bleeding from the arm is the great preserva-| 
tive; and this, as in wounded lungs, must 1)3 
done with a very liberal hand. When the I 
peritonaial inflammation has come on, the pa- 
tient must be assiduously preserved trom alii 
motion and irritation ; clysters of a mild! 
gentle kind must be injected, the belly ton! 
merited, and opiates administered. 
No food is to be given for the first ten orf 
twelve days ; nourishment is ts be conveyed! 
by clyster, or it any thing is taken by the 
stomach, it must be extremely mild and 
gelatinous. If the wound lias not penetrated 
the intestine, but part of the sound gut i: 
protruded, it must be'gently returned with 
the linger, and the outward wound stitched 
over it. 
When, from the passing out of the fa?ces,., 
it is evident that an intestine is wounded, this 
is not to be searched for with the linger, but 
suffered to remain ; and from the universal 
pressure among the parts, the outward andi 
inward wound will be brought opposite to! 
each other. If, however, the wounded in! 
testine is protruded, it is to be connectecf 
by a single stitch to the external wound, inf 
order that the faeces may be thrown out from 
this last, and the adhesive process en- 
couraged. 
When, through a narrow wound, a sounc 
bowel is obtruded, and becomes inflamed, 
the stricture is to be relieved by opening the 
wound a little wider, the intestine is to be 
carefully returned, and then the outer wounc 
stitched. 
Before we quit this subject of w'ounds, ar 
apology may be thought necessary lor en 
larging disproportionately on this division o 
the article. We have done so for the pur 
pose of illustrating the advantage that prac 
tical surgery has received from the natural 
as opposed to the artificial cure of wounds 
a fact which the young surgeon will find i 
necessary to impress on his mind as a direc 
tory in every step of his practice, whethe 
operative or medicinal. We shall concludi 
this section by an extract from an autho 
to whose incomparable treatise on wound 
we have been principally indebted for wha 
information the preceding observations 111 a 
have coveyed. 
“ It is an old, but it is a becoming and nit 
dest thought, that in our profession we ar 
but as the ministers of nature ; and, indeed 
the surgeon, still more than the physician 
achieves nothing by his own immediat 
power, but does all his services by observin 
and managing the properties ot the livih 
