(153) The patient was wounded at Paardeberg at a range of from 500 to 700 yards. _Entry_, just to the left of the episternal notch; _exit_, in the fifth left inters.p.a.ce posteriorly, midway between the spine and vertebral margin of the scapula. A quant.i.ty of bright blood was brought up at once, and later blood was coughed up in clots.

There was no great pain at the moment of the injury; the man again got up to the firing line, and later walked two miles to the Field hospital without aid. He remained here a week, when he was sent down to the Base, and during the first three days'

journey in the wagon he began to get worse. On the fourth day cough began to be very troublesome.

When he arrived at the Base, fifteen days after the original injury, there was much dyspnoea; the temperature was 102, and the pulse 110. The left side of the chest was dull throughout; an aspirating needle was introduced, and a pint of very dark liquid blood drawn off. The whole of the blood was not removed on account of the very severe cough and pain which the evacuation occasioned. The man appeared to steadily improve until three weeks later, when the temperature, which throughout had been uneven, became consistently high, and signs of fluid at the base increased. An aspirating needle was introduced, and 16 ounces of pus were drawn off. Two days later a piece of rib was resected (Mr. Pegg) and another pint of pus evacuated.

After this, rapid improvement took place, and in ten days the man was able to be up and dressed, although a small amount of discharge still persisted. He eventually made an excellent recovery.

Secondary empyemata not uncommonly followed incision of the chest, or excision of a rib for draining a haemothorax. These operations in the early part of the campaign were more freely undertaken on the supposition that rise of temperature and other symptoms of fever pointed to incipient breaking down of the clot. Subsequent experience showed this not to be the case, and early operations for drainage ceased to be undertaken. In these operations a primary difficulty was met with in effectively clearing out the clot, a drain had to be left, and suppuration occurred later in a considerable proportion. The suppurations were most troublesome; local adhesions formed, and the pus collected in small pockets, which were difficult to find and to drain, and even when the collections seemed to have been successfully dealt with at the time, residual abscesses often followed at a very late date.

Thus, I saw a case with a contracted chest and a fresh abscess the day before I left Cape Town, in whom I had advised and witnessed an operation for the evacuation of clot in the presence of signs of fever a week after my arrival in the country, nine months previously. I saw another case where general infection followed incision of a haemothorax, but the patient fortunately recovered.

The question of _pleurisy_ has already been mentioned in connection with haemothorax; it no doubt accounted for secondary effusion in some cases, and beyond this I have nothing to add to what has been there said.

_Pneumonia_ was rare; there were occasionally signs of consolidation, but, I think, quite as often in the opposite lung as in the one injured.

I never saw a fatal case, and I am inclined to think that when it occurred it was as often the result of cold and exposure as of the injury to the lung. Abscess of the lung I only saw once, and that in a case in which the injury to the chest was complicated by paraplegia from spinal injury and septicaemia, and it was possibly pyaemic.

_Diagnosis._--No difficulties special to small-calibre wounds were experienced, except such as have been already dealt with. The only cla.s.s of case which frequently gave rise to difficulty was haemothorax. Here two points especially needed consideration. (1) _The source of the haemorrhage as parietal or visceral._ As has been already foreshadowed, this was mainly to be decided by the amount and persistence of the haemoptysis, but naturally free haemoptysis did not negative concurrent parietal bleeding. Then the actual source of the bleeding other than from the lung had to be considered; in the great majority of cases the intercostal vessels were responsible, and attention to the course of the tracks often allowed this to be definitely decided upon.

A case included in the chapter on Injuries to the Blood Vessels (No. 5, p. 127) is of great interest in this particular; in that instance feebleness of the radial pulse, together with the position of the wound, was a valuable indication of injury to the subclavian artery, but weakened somewhat by the fact of retention of the bullet, and hence uncertainty as to the exact course that it had taken, and as to whether the bullet itself was not responsible for pressure on the vessel. Such indications, however, should make one very chary of interference with a haemothorax, even with extremely urgent symptoms, in the light of our present knowledge of the nature of the lesions to the great vessels produced by small-calibre bullets, and their tendency to be incomplete.

(2) _The imminence of suppuration or its actual occurrence._--In most cases it sufficed to preserve an expectant att.i.tude, and in the persistence or increase of symptoms, to have recourse to an exploratory puncture as the best means of solution of the difficulty.

_Prognosis._--The prognosis both as to life and as to subsequent ill-effects was remarkably good; in many cases of uncomplicated injury to the lung the patients rejoined their regiments at the end of a month or six weeks. In the more serious cases complicated by the collection of blood in the pleura, convalescence was more prolonged, and an average time of six to eight weeks often elapsed before the patients could be safely discharged from hospital. In the more serious a certain amount of dulness always persisted at this time over the base of the lung, and the chest was usually somewhat contracted on the injured side, with evidence in the way of decreased vesicular murmur that the lung was still not free from compression. With regard to the persistence of dulness on percussion, it is well to bear in mind that a thin layer of blood apparently produces as serious impairment of resonance as a much larger quant.i.ty of serum. The signs appeared to favour the view that the s.p.a.ce necessary for the location of the haemorrhage had been obtained at the expense of the lung rather than by distension of the thoracic parietes, and also, I think, denoted the presence of adhesions. Possibly they will entirely disappear with the return of full excursion movements of respiration, the latter being often still somewhat restricted when the patients left hospital. All the patients with such signs were liable to attacks of pain and shortness of breath on actual bodily exertion. I happened to meet with an officer, the subject of a Lee-Metford wound of the thorax, sustained five years previously, and he told me that he was nine months before he could take active exercise without feeling short of breath.

As to the cases of haemothorax and empyema which needed drainage, all did well; but expansion of the lung was much less satisfactory than would have been expected, probably on account of especially firm adhesions.

The importance of concurrent injury I need hardly dwell on; but I might add that perforation of one or both arms, the most common one, did not materially affect the general statements above made.

_Treatment._--In the early stages of the pulmonary wounds rest was the all-important indication, and when this was a.s.sured few serious cases of haemothorax occurred. Beyond simple rest, the administration of opium with a view to checking internal haemorrhage was used with good effect.

The wounds needed simple dressing only.

The treatment of haemothorax at a later date, however, was of much interest and difficulty. I think the following lines may be laid down for guidance in such cases:--

(i) Haemothorax, even of considerable severity, will undergo spontaneous cure. An early rise of temperature may be disregarded.

(ii) Tapping the chest is indicated when pressure signs on the lung are sufficiently severe to cause serious symptoms, and the removal of the blood undoubtedly shortens the period of recovery, as well as relieves symptoms.

In such cases the collection of blood has usually been rapid and continuous; hence a fresh haemorrhage is always probable when the local pressure has been removed. Tapping therefore should not necessarily mean complete evacuation, and should be followed by careful firm binding up of the chest, the administration of opium, and the most stringent precautions for rest.

(iii) Tapping may be needed as a diagnostic aid, and in such circ.u.mstances as much fluid as can be removed should be evacuated with the same precautions as mentioned in the last paragraph.

(iv) Tapping may be indicated for the evacuation of serum expressed from the blood-clot, or due to pleural effusion, on the same lines as in any other collection of fluid in the pleural cavity.

(v) Early free incision is, as a rule, to be steadfastly avoided. Some cases already quoted fully ill.u.s.trate its disadvantages.

(vi) Cases in which an incision and the ligature of a parietal artery are indicated are very rare. I never saw such a one myself.

(vii) If a haemothorax suppurates, it must be treated on the ordinary lines of an empyema. In view of the constant formation of adhesions and difficulty in drainage, a portion of a rib should always be resected in order to ensure sufficient s.p.a.ce for after-treatment. The cavities, as a rule, are better irrigated, the usual precautions being taken where there is any reason to fear that the lung is still in communication with the cavity.

Care in carrying out asepsis in tapping, which should be performed with an aspirator, need hardly be more than mentioned. It will be noted that in some of the cases quoted suppuration followed tapping, but it must be remembered that in these the two primary wounds already existed as possible channels of infection.

Retained bullets of small calibre in the thoracic cavity were not common, unless the lodgment had occurred in the bodies of the vertebrae.

I saw very few. Shrapnel bullets and fragments of sh.e.l.ls, however, were, in proportion to the frequency of wounds from such projectiles, more commonly retained. The rules to be followed in such cases do not materially deviate from those to be observed in the body generally.

When the bullet is causing no trouble, and is lodged in either the bone of the spine or the lung substance, no interference is advisable. When, on the other hand, the bullet as viewed by the X-rays is seen to be in the pleural cavity, and any symptoms of its presence exist, it may be justifiable to remove it. I saw this done in one case for the removal of a shrapnel bullet from the lower reflexion of the pleura on account of fixed pain and tenderness complained of by the patient. The bullet, a shrapnel, had perforated the arm, which the patient was sure was by his side at the moment of injury, and the X-rays showed it to lie at the bottom of the pleural cavity, where we a.s.sumed it had fallen. When, however, the bullet was removed by Mr. Watson, he found that the fixed pain and tenderness had been the result of a fracture of a rib from the inner side, not involving loss of continuity; hence the actual indication for the operation had been a delusive one, since the bullet had not fallen, but expended its last force in injuring the rib. The patient made an excellent recovery, and rejoined his regiment at the end of six weeks. I saw several cases in which the bullet was lodged in either the lung or bones of the spine do well with no interference. The great disadvantage of primary removal in inducing an artificial pneumo-thorax and in laying open a haemothorax is obvious.

In case of lodgment of the bullet in the lung, bearing in mind the infrequency of untoward symptoms, the latter should be watched for prior to interference.

The following cases ill.u.s.trate some typical instances of wound of chest accompanied by the development of haemothorax:--

[Ill.u.s.tration: TEMPERATURE CHART 3.--Primary Haemothorax, with rise of temperature. Secondary rise, with fresh effusion and pneumonia.

Spontaneous recovery. Case No. 154]

(154) _Severe haemothorax. Spontaneous recovery._--Wounded at Modder River at a distance of 30 yards. _Entry_, at the junction of the left anterior axillary fold with the chest-wall; _exit_, immediately to the left of the seventh dorsal spinous process. The patient arrived at the Base with signs of an extensive haemothorax, accompanied by a temperature which reached 102 on the fourth day, and on the evening of the tenth 103. The man was very ill, and an exploring needle was inserted, by which about an ounce of blood was evacuated. The signs of fluid in the left pleura were accompanied by those of consolidation over the lower fourth of the right lung, and the sputa were rusty. Evidence of perforation of the left axillary artery existed in feebleness of the radial pulse; and there was musculo-spiral paralysis.

After the preliminary puncture, the man refused any further operative treatment, although a second rise of temperature commenced on the fifteenth day, culminating in a temperature of 103.2 on the eighteenth. The further treatment of the patient consisted in the ensurance of rest and the alleviation of pain.

A steady fall in the temperature extended over another three weeks, together with diminution in the signs of fluid in the pleura. At the end of seventy-four days the man was sent home, some slight dulness at the left base, and contraction of the chest sufficient to influence the spine in the way of lateral curvature, being the only remaining signs.

[Ill.u.s.tration: TEMPERATURE CHART 4.--Primary Haemothorax. Secondary rise of temperature, with increase in the effusion. Spontaneous recovery.

Case No. 155]

(155) _Severe haemothorax. Secondary effusion. Spontaneous recovery._--Wounded at Koodoosberg Drift, at a distance of 200 yards. _Entry_, at angle of the right scapula; _exit_, at the junction of the left anterior axillary fold with the chest-wall. No signs of spinal cord injury. The patient was brought in from the field twelve miles by an ambulance wagon on the second day, and in crossing the Modder River he was accidentally upset into the stream. For the first four days there was no haemoptysis, but for the succeeding nine days small brightish red clots were expectorated. There was some tenderness over the ribs from the fifth to the ninth in the axillary line, and on the ninth day some gravitation ecchymosis appeared over the same region. Cough was an early troublesome symptom in this case, and when admitted to the Base hospital, about the seventh day, there was evidence of fluid extending about a third of the way up the back.

On the tenth day after admission a pleural rub was detected at the upper margin of the dulness, and the latter shortly extended upwards over a little more than half the back.

Meanwhile, there was no further haemoptysis, respiration was fairly easy, 24 per minute, but accompanied by slight dilatation of the alae nasi, and the temperature, which had been ranging from 99 to 100, began to rise steadily, on the fifteenth day reaching 102.5. The patient refused even an exploratory puncture, and was treated on the expectant plan.

The temperature slowly subsided, with a steady improvement in the physical signs, and at the end of about ten weeks he left for home with only slight dulness and incapacity for active exertion remaining. (Now again on active service.)

[Ill.u.s.tration: TEMPERATURE CHART 5.--Haemothorax, primary and secondary rises of temperature, on each occasion falling on the evacuation of the blood. Case No. 156]

(156) _Severe haemothorax. Recurrent secondary effusion. Tapping on two occasions. Cure._--The patient was wounded at Paardeberg, and arrived at the Base on the eighteenth day.

_Entry_, below the first rib, just external to its junction with the costal cartilage; _exit_, through the ninth rib, just within the posterior axillary line. The whole right side of the chest was dull, with signs of the presence of fluid, the heart being displaced to the left. There was considerable distress; the respirations averaged 40, the pulse 100, and the temperature reached 101.5 the first evening after arrival.

On the nineteenth day the thorax was aspirated (Mr. Hanwell) and 50 ounces of dirty red-coloured fluid, half clot, half serum, were evacuated. Considerable relief was afforded; the respirations became slightly less frequent; the heart returned to a normal position, and distant tubular respiration was audible. The temperature dropped to normal the third day after evacuation of the fluid, but on the sixth day it again commenced to rise, and meanwhile fluid again began to collect.

On the twenty-sixth day a second aspiration resulted in the evacuation of 35 ounces of b.l.o.o.d.y fluid in which flakes of lymph were found. Three days later the temperature became normal. The respirations fell to 22, and the patient made an uninterrupted recovery.

[Ill.u.s.tration: TEMPERATURE CHART 6.--Wound of Lung. Secondary development of Haemothorax, with rise of temperature. Spontaneous recovery. Case No 157]

(157) _Moderate haemothorax. Secondary effusion at the end of twenty days. Spontaneous recovery._--Wounded at Paardeberg; range from 700 to 1,000 yards. _Entry_, in the centre of the second right intercostal s.p.a.ce, anteriorly; _exit_, at the level of the sixth rib posteriorly, through the scapula, close to its vertebral margin.

The patient arrived at the Base on the sixth day; he said he expectorated some blood at the end of about ten minutes after being shot, and experienced a 'half-choking sensation.' A small quant.i.ty of phlegm and occasional clots had been expectorated since. He had walked about a good deal; movement occasioned cough, and he became 'blown' very rapidly.

On admission there were signs of fluid in the lower third of the pleural cavity, but no general symptoms beyond an evening rise of temperature to an average of 99. About the twentieth day the temperature commenced to rise, and on the twenty-third and four following evenings reached 102. The fever was accompanied by some distress, and a well-marked increase in the physical signs of the presence of fluid in the chest. The pulse rose to 96, and the respirations considerably above the average of 24, which was at first noted. A strictly expectant att.i.tude was maintained, and the temperature steadily fell in a curve corresponding to the rise, gradually reaching the normal at the end of a week. The physical signs at the base steadily cleared up, and at the end of six weeks the patient returned to England convalescent.

CHAPTER XI

INJURIES TO THE ABDOMEN