(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 interspace posteriorly, midway between the spine and vertebral margin of the scapula. A quantity 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 dyspnœa; 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 hæmothorax. 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 hæmothorax, but the patient fortunately recovered.
The question of pleurisy has already been mentioned in connection with hæmothorax; 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 septicæmia, and it was possibly pyæmic.
Diagnosis.—No difficulties special to small-calibre wounds were experienced, except such as have been already dealt with. The only class of case which frequently gave rise to difficulty was hæmothorax. Here two points especially needed consideration. (1) The source of the hæmorrhage as parietal or visceral. As has been already foreshadowed, this was mainly to be decided by the amount and persistence of the hæmoptysis, but naturally free hæmoptysis 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 hæmothorax, 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 attitude, 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 quantity of serum. The signs appeared to favour the view that the space necessary for the location of the hæmorrhage 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.