Any return of the oppression will show the necessity for further depletion. In wounds from gun-shot, the patient should be allowed to lie in the position which he chooses; but if the wound be a stab, the position prescribed should be that which will favour the adhesion of the pleurae; and when there is effusion within the thorax, that which will allow of its escape. To determine whether the blood which flows from a wound in the thorax proceeds from a wounded intercostal or from the lung, has called forth more acumen and research than it would appear to merit. The difficulty will be greatest when a knife has been the instrument, and the wound made is very oblique. In large wounds, Sanson lays down the following means of diagnosis: 1.
Whether the blood be arterial or venous; 2. By turning out with forceps the lips of the wound, and seeing whether the blood proceeds from one of these lips; 3. By compressing the superior lip of the wound with * " Until the danger of immediate death from haemorrhage is over,"?ays Ilennen, " we must not think of employing anything except depletion by the lancet; it, and it only, can save the life of the wounded man." " It is only hy these repeated bleedings," says John Bell, " that the patient can be saved. The vascular system must be kept low in action, and so drained as to prevent the lungs from being oppressed with blood.
One thing is very clear," he adds, " that if the surgeon bleed only when the cough and bleeding from the lungs return, he never can do wrong." Tin: iv ST. the inferior border of upper rili. where intercostal may he a roll of card introduced iii the. because when th;'.t can he done we may be able to see the wounded vessel with the eye; but the examination undinu- instrument will often show whether it could penetrate deep enoii-h to injure' the Lung. iin.ir from the lung makes itself apparent by both rational and physical signs. Some of these arc e'lnnion to all ha'inorrhuges, external or internal, while in intra-thoracic effusions of whatever.iption.
Of the rational signs, paleness of tin; coldness of the surface, a small, eoneentrated, and quirk pulse, iriddiness, and syncope are those referable to loss of blood; while the sometimes amoiintto suffocation, the feeling of weight in th restlessness, and tlie decubitus on the wounded side belong to all effusions. Tin- physical E are also common to all effusions. They are a dilated chest, little moved du i-iration, bulged inti-rmsta! spaces, dullness on rueh a e 'in which are reeo-ni/.ahle by percussion Miseultatioii. The pecnliai celiymosis described by i which results from the escape of blood into iil.eiitaneou- cellular tissue, seldom appears; but if it does, it 18 According to many a valuable sign of mentions having seen patients perifih of in whom the breathing was not disturbed, and who could lie in any poeirhagic If, then, after a gun-shot wound of the thorax, we have those signs present which would indicate the loss of blood, as well as those which indicate the existence of fluid in the pleura, embarrassing the functions of the contained viscera, the diagnosis is plain.
If blood;>e by the external wound during respiration, or after a cough, the opinion will be strengthened that blood has been poured out, and occupies the pleural sac. The danger from haemorrhage is greatest durinir the first twelve hours, and is pretty well over by the second day. A flow may however continue, in greater or less quantity, for eight or ten days, but then it is seldom to any serious amount. If the quantity of blood effused be small, it will probably be absorbed; but if it is in large quantity, and especially if air is also present, the gravity of the lesion is much augmented. So soon as all fear f a renewal of the bleeding is over, the effused blood, if in quantity, should be evacuated by operation; but, as Sanson says, it is better to be a little late than too early in taking this step.f * Luez remarks upon this point " Valentin pretends that the ecdiymosis which is observed on the loins, in wounds of the thorax, is a pathognomonic symptom of effusion into the pleura, and that its absence i< a counter-indication to paracentesis.