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 interstitial blood effusions already mentioned elsewhere.
The common course of all the cases of hæmothorax was to spontaneous recovery, the rapidity of the subsidence of the signs depending mainly on the quantity of the primary hæmorrhage, 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 hæmorrhage followed by inflammatory troubles:—
Temperature Chart 2.—Secondary Hæmorrhages in a case of Hæmothorax. 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 space; exit, at the back of the right arm 1½ inch below the acromial angle; both pleuræ were therefore crossed. The patient expectorated at first fluid, then clotted, blood in considerable quantity. 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, reaccumulation took place, the evacuated fluid assumed an inflammatory character, and an incision to evacuate pus was eventually followed by death on the twenty-seventh day. The amount of hæmoptysis throughout was considerable, and the case was possibly one of pulmonary hæmothorax, as after death no source of hæmorrhage could be localised in the intercostal space. 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 illustrating 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 hæmoptysis, but the patient suffered with some dyspnœa 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 illustrates the symptoms in a severe case of hæmothorax, and empyema following aspiration:—