In some other patients in whom the track pa.s.sed close below the heart a disturbance of the pulse rate was noted, but this was in some cases a slowing, not below 48, in others quickening to 100, with irregularity both in force and beat.

(146) _Entry_, in the fourth right inters.p.a.ce, 3 inches from the middle line; _exit_, in the seventh left inters.p.a.ce, in the mid-axillary line. This wound was received at a distance of 500-600 yards, but the bullet penetrated both sides of a stout silver cigarette case and some cigarettes before entering the body. There were minor signs of pulmonary injury, 'coughing day and night,' and slight discoloration of the sputum on three or four occasions. The respirations were quickened to 32, and as much as ten days after the injury the pulse only beat 48 to the minute; it then rose to 56, but beat in a very deliberate manner.

In other cases the signs were almost nil.

(147) _Entry_, in the fourth right intercostal s.p.a.ce 3/4 of an inch from the sternum; _exit_, in the sixth left inters.p.a.ce in the posterior axillary line. This patient had no symptoms, beyond quickening of the pulse to 100, and a 'feeling of tightness at the heart.' He shortly returned to active duty.

(148) _Entry_, situated in the third right inters.p.a.ce 3 inches from the sternal margin; _exit_, in the fourth left s.p.a.ce 2-3/4 inches from the sternal margin. In this case the bullet without doubt pa.s.sed through the anterior mediastinum, and slight injury to the lung was evidenced by transient haemoptysis.

Some remarks regarding wounds of the thoracic vessels have already been made in Chapter IV., where instances of injury to the innominate and left subclavian arteries are recounted. The escape of the large trunks was generally quite as astonishing as in other parts of the body, especially in the superior mediastinum.

(149) _Entry_, over the first right intercostal s.p.a.ce beneath the centre of the clavicle; _exit_, at left anterior axillary fold. The great vessels must have been crossed here in immediate contact, and considerable haemorrhage from the wound of entry caused great anxiety; this ceased spontaneously, however, and, beyond transient haemoptysis and a right pneumo-thorax, no further trouble occurred.

(150) _Entry_, in the ninth inters.p.a.ce, just anterior to the anterior axillary line; _exit_, through the right half of the sternum, 1/2 an inch below the upper border. No primary haemorrhage of importance followed, but I believe this patient subsequently died. The wound was received at a range of within fifty yards.

_Wounds of the lungs._--Numerically, pulmonary wounds formed the most important series of visceral injuries met with in the thorax, the frequency of incidence corresponding with the proportionate sectional area occupied by the organs. Although these injuries did well, and needed little interference on the part of the surgeon, many points of interest were raised by them.

Thus the comparative importance of the wound in the chest-wall to that in the lung itself, was scarcely what, without actual experience, would have been expected, the former proving so very much the more important element of the two.

The question of velocity on the part of the bullet took a very secondary position in these injuries. I saw a number of cases in which the patients estimated the range at which they received their wounds as from 30 to 50 yards, and although some of the wounds were of a severe type, the increased gravity depended rather on the injury to the chest-wall than to that of the lung. If the bullet pa.s.sed by the intercostal s.p.a.ce, avoiding the rib, I very much doubt if the relative velocity was of any importance, further than from the fact that a sufficiently low degree to allow of lodgment of the bullet was distinctly unfavourable.

In view of the general lack of significance in these injuries it was interesting to note how very definite was the ill effect of early transport on the after course. This depended on the frequent development of parietal haemothorax in patients who were not kept absolutely at rest.

The tracks produced in the lungs by the bullets were very minute, and in the few cases in which opportunity arose for their examination _post mortem_ some little time after the infliction of the wound, there was great difficulty in localising them. The slight damage incurred by the pulmonary tissue is due to its elasticity and non-resistent character.

Pulmonary haemothorax was distinctly rare. Reasoning from the a.n.a.logous wounds of the liver, tracks scoring the surface of these organs might be much more to be feared than clean perforations. The elasticity of the lung tissue, however, must make such lesions rare. In point of fact, there is no reason why a perforation by a bullet of small calibre should be much more feared than a puncture from an exploring trocar, and the danger of the two wounds is probably very nearly the same.

The only points of importance as to the particular region of the lung traversed were the distance from the periphery as affecting the probable size of the vessels injured, and perhaps the implication of the base or apex of the organ respectively. I am under the impression that wounds in the apical region were somewhat more liable to be followed by the development of pneumothorax, and possibly haemothorax, while wounds at the base gained their chief importance from the frequency of concurrent injury to the abdominal viscera. I had no experience of the immediate results of wound of the great vessels at the root of the lung, but a.s.sume that they led to speedy death.

_Symptoms of wound of the lung._--I shall describe the whole complex usually observed, although it is obvious that the wound of the chest-wall is responsible for a large proportion of the signs.

The majority of these injuries were accompanied by a certain degree of systemic shock, and this was more marked in wounds received at a short range. The shock was, however, rather to be attributed to the injury to the chest-wall and thoracic concussion than to that to the lung itself.

I think it may also be stated that few patients were inclined to walk or remain in the erect position after receiving these wounds; this feature was also noted in horses in whom a bullet pa.s.sed through the lungs.

The remarks made as to the pain accompanying fractures of the ribs apply equally here. Pain was not a prominent symptom, except in so far as the actual impact caused temporary suffering. It was striking how often patients who received wounds through the arm prior to the same bullet traversing the chest appreciated the chest wound only, yet the chest might pa.s.s unnoticed when a still more sensitive part was struck later, as has been already mentioned in the section on wounds in general.

Dyspnoea was not a prominent primary symptom. The patients sometimes had 'all the wind knocked out of them' at the moment of impact, but when seen at the Field hospitals a short time later, the respirations were shallow, but easy and regular, and only moderately quickened; thus 24 was a not uncommon rate. Naturally if acc.u.mulation of blood in the pleura began early and continued, these remarks do not hold good; and again in some older men of full-blooded type and the subjects of recurrent attacks of bronchitis, a considerable degree of pain, dyspnoea, and even cyanosis was sometimes present soon after the injury. The complication of wound of the diaphragm has already been referred to in this relation.

Local respiratory immobility of the thoracic parietes and consequent asymmetry of movement were constant. This was especially a marked feature when the upper part of the chest was implicated on one side only. It rather corresponded, however, to the local shock observed in wounds of the limbs than to the instinctive immobility accompanying fractures of the ribs; since, as already explained, small-calibre bullet wounds of the ribs are not necessarily painful on movement, and the sign existed even when the bullet had pa.s.sed by an intercostal s.p.a.ce. This sign was naturally a transitory one.

Haemoptysis was a fairly constant sign, but sometimes quite absent when no doubt could exist as to the perforation of the lung. As a rule, a considerable quant.i.ty of blood might be coughed up shortly after the injury; but I never knew this to be sufficient in amount to give rise to any misgivings as to danger from the haemorrhage. After the first evacuation of blood from the wounded lung, the sign varied much; in the majority of instances the patients continued to expectorate small quant.i.ties of blood mixed with mucus, for some three or four days, the blood gradually a.s.suming a coagulated condition. Sometimes only the primary haemoptysis was noted, and still more rarely the expectoration of clots was continued for a week, or even longer. This probably depended partly on personal idiosyncrasy, partly on the size of the vessels which had been implicated in the track.

Cough was not commonly the troublesome symptom noted in the contused wounds of the lung seen in civil practice accompanying fracture of the ribs. Moist sounds were usually audible on auscultation, but in many cases over a very limited area and only on the first few days.

Cellular emphysema was distinctly rare, and usually limited in extent: thus I saw it in the posterior triangle of the neck alone in an apical wound; over about a third of the upper part of the thorax in another wound through the second intercostal s.p.a.ce, and in this case oddly enough the emphysema was the only sign of injury to the lung; and very occasionally widely distributed--in the latter case there were also usually multiple fractures of the ribs. Neither issue of air from the external wound nor frothy blood was ever seen with small-calibre wounds, but I saw one instance in a case of Martini-Henry wound.

_Pneumothorax_ was also rare. I saw pneumothorax three times out of about half a dozen Martini-Henry wounds, but I do not think it occurred as often in 100 small-calibre wounds. The Martini-Henry wounds all recovered; but convalescence was very prolonged, and the same remark to a less degree holds good in the small-calibre cases.

That the slow recovery in cases of pneumothorax in the Martini-Henry wounds was due mainly to the size of the opening in the thoracic parietes was, I think, proved by the fact that in the small-calibre bullet wounds, followed by the development of pneumothorax, the external wounds were usually large and irregular in type; also, that in the only pneumothorax which I saw produced during an extraction operation, the air was very rapidly absorbed. In the latter case, however, there was little reason to conclude that wound of the lung had occurred primarily, and certainly no opening existed at the time the thorax was incised.

_Haemothorax._--This was the most frequent and also the most interesting of the complications of wound of the chest. In 90 per cent. or more of the cases, the haemorrhage was of parietal source, and due either to direct injury to the intercostal vessels by the bullet or to laceration by spicules of comminuted ribs. For this reason, the pa.s.sage of the bullet whether by an intercostal s.p.a.ce, or through a rib, provided the wound was not at the posterior part of the s.p.a.ce where the artery crosses, was a point of considerable prognostic importance. Exclusion of the lung as the source of haemorrhage was, I think, amply justified by the absence of continuous recurrent or progressive haemoptysis in the majority of the cases, and by the very small trace of injury found in the lungs of patients who died some weeks after the injury. In such it was difficult to discriminate the tracks at all. I only happened to see one case where free haemoptysis, during the course of development of a haemothorax, pointed to the lung as the source of the blood.

Haemorrhage into the pleural cavity occurred in some degree in a very large proportion of the chest wounds, but it was especially interesting to note how greatly its extent was influenced by the amount of transport to which the patients were subjected in the early stages after the injury. During the early part of the campaign, on the western side, I saw a large number of chest wounds, and had I been asked my opinion as to the relative frequency of occurrence of haemothorax I should have placed it at about 30 per cent. The patients in these early battles needed little wagon transport, and when sent down to the Base travelled in comfortable ambulance trains. After the commencement of the march from Modder River to Bloemfontein, however, these conditions were changed, and all the chest as other cases were exposed to the necessity of three days and nights' journey to the Stationary hospitals and afterwards to the long journey to Cape Town. Of these patients, at least 90 per cent. suffered with haemothorax of varying degrees of severity.

In some cases, the least common, signs of considerable intra-pleural haemorrhage immediately followed the wound; in others, the acc.u.mulation of blood was gradual, and only manifest in any degree at the end of three or four days, when it became stationary if the patient was kept at rest. In a second series the haemorrhage was of the recurrent variety; these cases differing little in character from those of slight continuous haemorrhage. In a third, the bleeding was definitely of a secondary character, corresponding with one of the cla.s.ses of secondary haemorrhage described in Chapter IV., and occurring on the eighth or tenth day from giving way of an imperfectly closed wounded vessel. In either of the two latter cla.s.ses the development of the haemothorax often corresponded with a journey, or with allowing the patient to get up.

The general course of these effusions was towards spontaneous absorption and recovery. Coagulation of the blood took place early, the fluid serum separated, and tended to undergo absorption with some rapidity, leaving a small amount of coagulum at the base, which evidenced its presence for many weeks by a persistence of a certain degree of dulness on percussion. Early coagulation, I think, accounted for the usual absence of gravitation ecchymosis as a sign.

The course to recovery was sometimes broken by signs of slight pleuritic inflammation, which, as affecting the amount of effusion, will be spoken of under the heading of symptoms. In some cases the amount of blood was so great as to necessitate means being taken for its removal; in these a reacc.u.mulation often took place. Occasionally an empyema followed in cases thus treated.

The nature of the blood evacuated on tapping varied much. In very early aspirations unchanged blood was often met with, but clot sometimes made evacuation difficult and necessitated a second puncture. In the tappings done at the end of a week or more a dark porter-like fluid was common, while when suppuration was imminent a brick-red-coloured grumous fluid replaced normal blood. In the cases where early incision was resorted to, blood both fluid and in clots was often mixed with a certain proportion of lymph flakes, perhaps indicating the part taken by inflammatory reaction to the irritation of the clot in producing the rise of temperature.

_Symptoms of haemothorax._--In the more severe cases of primary bleeding the symptoms did not, as a rule, reach their full height until the third or fourth day after the injury. The patients then often suffered severely. The pulse and temperature rose, and to general symptoms of loss of blood were added: occasional lividity of countenance; severe dyspnoea, accompanied by inability to lie on the sound side or to a.s.sume the supine position; absence of respiratory movement on the injured side; pain, restlessness, cough, and sometimes continuance of haemoptysis, small clots usually being expectorated.

Accompanying these symptoms were the usual physical signs of fluid in the pleura in differing degrees and combination. Dulness of varying extent up to complete absence of resonance on one side, often accompanied in the incomplete cases by well-marked skodaic resonance anteriorly. Loss of vocal resonance, and fremitus; oegophony, tubular respiration over the root of the lung or at the upper limit of the dulness, and more or less extensive displacement of the heart. Obvious increase in girth, fulness of the intercostal s.p.a.ces, or gravitation ecchymosis was rare. The latter was most common in instances in which multiple fracture of the ribs existed (see fig. 83). I think the rarity of the last sign must have been due to the early coagulation of the blood, and its retention by the pleura, as I saw well-marked gravitation ecchymosis in one or two cases of mediastinal haemorrhage.

The above complex of symptoms was common to all the cases, but in the slighter ones they gave rise to little trouble, and cleared up with great rapidity.

[Ill.u.s.tration: FIG. 83.--Gravitation Ecchymosis in a case of Haemothorax, accompanying fracture of three ribs from within. The influence of the fractures on the development of the ecchymosis is shown by the linear arrangement of the discoloration]

The most interesting feature was offered by the temperature, as this was very liable to lead one astray. A primary rise always occurred with the collection of blood in the pleura, this reaching its height on the third or fourth day, usually about 102 F. in well-marked cases; it then fell, and in favourable instances remained normal. In a large number of cases, however, where the amount of blood was considerable, this was not the case, the primary fall not reaching the normal, and a second rise occurred which reached the same height as before or higher. The second rise was accompanied by sweating, quickened pulse, and the probability of the development of an empyema had always to be considered. I believe in most cases this secondary rise was an indication of a further increase in the haemorrhage, for the dulness usually increased in extent, and such rises were often seen when the patient had been moved or taken a journey. Again, the temperature often fell to normal after paracentesis and removal of the blood, to rise again with a fresh acc.u.mulation, which was not uncommon. I have already mentioned the large proportional incidence of haemothorax observed in the patients who had to travel down from Paardeberg, and I might instance another case related to me by Dr. Flockemann of the German ambulance, which was very striking. A Boer, wounded at Colesberg, developed a haemothorax which quieted down, and he was removed to Bloemfontein; on arrival at the latter place the temperature rose, and other signs of fever suggested the development of an empyema; an exploring needle, however, only brought blood to light. After a short stay at Bloemfontein the symptoms entirely subsided, and the man was sent to Kroonstadt, when an exactly similar attack resulted, again quieting down with rest.

Similar recurrent attacks of haemorrhage and fever occurred, however, in patients confined to their beds without moving after the first journey.

Some temperature charts, in ill.u.s.tration of this point, are added to the cases quoted later. The explanation of the recurrent haemorrhages is, I think, to be found in the reduction of the intra-thoracic pressure with coagulation and shrinkage of the clot in the pleura in the patients kept quiet in bed, while in the patients who had to travel it was probably the result of direct mechanical disturbance.

In many of these cases a pleural rub was audible at the upper margin of the dulness with the development of the fresh symptoms. Whether this was due to actual pleurisy or to the rubbing of surfaces rough from the breaking down of slight recent adhesions which had formed a barrier to the effusion, I am unable to say, but the signs were fairly constant. In some instances the increase in the amount of fluid was, no doubt, due to pleural effusion resulting from irritation from the presence of blood-clot, or perhaps the shifting of the latter; in these the secondary rise of temperature may well be ascribed to the development of pleurisy.

I am inclined to believe, however, that the primary rise of temperature was similar to that seen when blood acc.u.mulates in the peritoneal cavity as the result of trauma, and the secondary rises in most cases to those which we saw so frequently accompanying the interst.i.tial secondary haemorrhages spoken of in Chapter IV., and are to be explained on the theory of absorption of a blood ferment. The secondary rises always occurred with a fresh effusion, often of blood, occasioning an extension, which broke down probable light adhesions and exposed a fresh area of normal pleural membrane to act as a surface for absorption.

It is, of course, manifest that the fever might also be ascribed to the infection of the clot or serum from without, and in the first cases I saw I was inclined to take this view, since we had in every case the primary wounds of chest-wall, and possibly of lung, and in some the addition of a puncture by an exploring needle between the first and second rise. After a wider experience, however, I abandoned the infection theory, as it seemed opposed by the very infrequent sequence of suppuration. The effect of simple removal of the blood or serum was also often so striking as to strongly suggest that it alone was responsible for the fever. Exactly the same result, moreover, followed evacuation of the interst.i.tial blood effusions already mentioned elsewhere.

The common course of all the cases of haemothorax was to spontaneous recovery, the rapidity of the subsidence of the signs depending mainly on the quant.i.ty of the primary haemorrhage, and the occurrence of further increases. The blood serum tended to collect at the upper limit of the original blood effusion (as was often proved on tapping), and this was first absorbed; the clot deposited on the pleural surface and at the basal part of the cavity was, however, not absorbed with the same rapidity. In the majority of the patients when they left the hospitals, at the end of six weeks on an average, some dulness and deficiency of vesicular murmur always remained, and the clot and the surrounding surface, irritated by its presence, will, no doubt, be responsible for permanent adhesions in many cases. That such adhesions do form in the majority of cases I feel certain, as, although these patients when they left the hospital were to all intents and purposes apparently well, few of them could undertake sustained exertion without getting short of breath, and sometimes suffering from transitory pain, and for this reason it became customary to invalid them home.

In a small proportion of the cases empyema followed; but I never saw this in any case that had neither been tapped nor opened, and I saw only one patient die from a chest wound uncomplicated by other injuries.

This case was an interesting one of recurrent haemorrhage followed by inflammatory troubles:--

[Ill.u.s.tration: TEMPERATURE CHART 2.--Secondary Haemorrhages in a case of Haemothorax. Case No. 151]

(151) The wound was received at short range, probably at from 100 to 200 yards. _Entry_, 1 inch from the left axillary margin in the first intercostal s.p.a.ce; _exit_, at the back of the right arm 1-1/2 inch below the acromial angle; both pleurae were therefore crossed. The patient expectorated at first fluid, then clotted, blood in considerable quant.i.ty. When brought into the advanced Base hospital on the third day, there were signs of blood in the left pleura, cellular emphysema over the right side of the chest, and signs of collapse of the right lung. The temperature chart gives shortly the course of the case: the right pneumo-thorax cleared up spontaneously, also the emphysema; but the left pleura needed tapping to relieve symptoms of pressure on four occasions, the 13th, 15th, 19th, and 25th days respectively. On the first two occasions blood was removed, on the third blood serum only, and on the last pus. The patient was relieved after each aspiration; after the third, the temperature fell to normal, the general condition also improved, and he promised to do well. None the less, reacc.u.mulation took place, the evacuated fluid a.s.sumed an inflammatory character, and an incision to evacuate pus was eventually followed by death on the twenty-seventh day. The amount of haemoptysis throughout was considerable, and the case was possibly one of pulmonary haemothorax, as after death no source of haemorrhage could be localised in the intercostal s.p.a.ce. The track in the lung was almost healed, and although a part of it allowed the introduction of a probe for about an inch, it could be traced no further even on section of the organ, and no special vessel could be located as the original bleeding spot.

_Empyema._--I may here add the little that I have to say on this subject. During the whole campaign the single case of primary empyema that I saw was the one recorded below, which deserves special mention as ill.u.s.trating the disadvantage of extracting bullets on the field. Under the conditions which necessarily accompanied this operation the ensurance of asepsis was impossible, and the additional wound no doubt proved the source of infection.

(152) _Entry_, at the posterior margin of the sterno-mastoid muscle, 2 inches above the clavicle; the bullet came to the surface beneath the skin over the fifth rib, in the nipple line of the right side. There was never any haemoptysis, but the patient suffered with some dyspnoea throughout. After a three days' stay in the Field hospital, where the subcutaneous bullet was removed, the patient was transported by wagon and train to the Base, a journey of about 600 miles.

On the fifth day pus escaped from the extraction wound, and when the case was examined at the Base, the temperature was 101, the pulse over 100, the respirations 30, and the whole side of the chest was dull, with the exception of a patch of boxy resonance over the apex anteriorly. On the following day the chest was drained, and a considerable amount of pus evacuated, which was mixed with breaking-down blood-clot. A fortnight later a second operation had to be performed to improve the drainage, and the patient made a tedious recovery.

The following case well ill.u.s.trates the symptoms in a severe case of haemothorax, and empyema following aspiration:--