For official use only 5 340 300 MEDICAL RESEARCH COMMITTEE ?! STATISTICAL REPORTS 8 3 6 9 No. 4.- 600 CASES OF GUNSHOT WOUND OF THE CHEST February 27, 1919 i. TN close relation to the work the Medical Reseai-ch Committee have undertaken for the Army Council in the compilation of the formal Medical Statistics of the War, the Committee have provided accessory help in various directions for the collection and preservation of medical records and of the after-histories of military patients, with a view both to the present guidance of medical officers and to the future purposes of the Medical History of the War. This accessory statistical work has been effected by the arrangements made for the interchange of informa- tion between separate medical units overseas and between those overseas and at home, by the schedule system of collecting information in chosen series of cases, by clerical help supplied for tracing personal histories after discharge, and in other ways. Many communications giving statistical summaries of the results of treatment in various classes of medical and surgical patients have already been published by permission in medical journals, and others have been given in several of the reports issued or published by the Committee. With the sanction of the Director-General, A. M.S., the Committee have made arrangements to issue from time to time for official distribution statistical summaries which, whether from their provisional nature or for other reasons, are not proposed for publication elsewhere. STATISTICAL EEPORTS No. 1. 656 Cases of Gunshot Wound of the Head. (June 13, 1918.) No. 2. Gunshot Wound ; Compound Fracture of Femur, and Penetra- tion of Hip and Knee Joints. (August 8,- 1918.) No. 3. An Analysis of 8,670 Ophthalmic Cases treated at a Home Hospital. (January 22, 1919.) No. 4. 600 Cases of Gunshot Wound of the Chest. (February 27, 1919.) Wt. P2094. 223. 750. 4/19. U.P. STATISTICAL AND CLINICAL REPORT ON 600 CASES OF GUNSHOT WOUND OF THE CHEST BY J. M. FORTESCUE-BRICKDALE, M.D., M.R.CR, CAPT. R.A.M.C. (T.F.) CONTENTS I. INTRODUCTION . . . '. . If. DURATION OF STAY IN HOSPITAL . . . III. DISPOSAL OF CASES . . ' IV. ULTIMATE RESULTS . . . V. EFFECTS OF BULLETS AND SHEIL FRAGMENTS VI. EMPYEMAS ..... (1) Primary empyemas . (2) Secondary empyemas . ' . VII. EARLY OPERATIVE TREATMENT . . VIII. HAEMOTHORAX . ". (1) Results of aspiration . ''. (2) Delayed absorption . _. . IX. BACTERIOLOGICAL FINDINGS , (1; Variety of organisms t ' J . ' (2) Lightly infected eases . i X. CELL COUNTS . . . . XI. GROCCO'S PARAVERTEBRAL TRIAKGLE XII. COMPLICATIONS .... XIII. LATB SYMPTOMS . . . .. XIV. TRANSPORT TO ENGLAND . I. INTRODUCTION. THIS report deals with 600 cases which have been admitted to the Centre for gunshot wounds of the chest at Southmead, Bristol, since its inception in February 1917, and discharged before the end of November 1917. The large majority of cases came direct from France, a few were transferred to the Centre from other A3 hospitals in England, and a few came from the Eastern theatres of war. The following table shows the numbers in the various classes of case admitted : TABLE I. Empyema Haemo- and pneumothorax Penetrating wounds without effusion Non-penetrating wounds 70 = 11 per cent. 375 = 62 97 = 16 j8= 9 600 For purposes of record the cases were divided into three main classes as follows : Class 1. Primary empyema. (i) Open. (ii) Healed. Class 2. Early operation. (i) In which the pleura has been opened, with or without incision of the lung. (a) "Without further surgical treatment. (&) In which a secondary operation for em- pyema has been performed. (ii) In which the external wound only has been excised. | Same as in 2 (i). Class 3. Cases in which no operation has been performed. (i) Requiring operation. (a) For empyema. (6) For removal of foreign body. (c) For clottepl haemothorax. (ii) Not requiring operation. (a) Aspirated in France. (b) Aspirated after admission. (c) Not aspirated. II. DURATION OF STAY IN HOSPITAL. The actual stay in hospital from the date of the wound in France or elsewhere has been ascertained in 324 cases. This period includes the time spent in Convalescent Auxiliary Hospitals, but not time spent at Command Depots. It was found advisable in all cases to retain patients in hospital until they were thoroughly fit, both in general condition and as to their local lesions; the greater number spent some weeks at a Convalescent Hospital, but a fair proportion were discharged from the Centre direct to Command l)epot or duty. TABLE II. All Classes. 324 cases ; average number of days in hospital 92 ; of which an average of 20 were spent in France. Empyemas. 31 cases. In hospital 195 days (France 61}. All other cases 293 cases. In hospital 81 days (France 16). Intrathoracic operation cases; excluding empyemas. 21 cases. In hospital 129 days (France 31). Excision of external icound, excluding empyemas. -, Penetrating wounds 23 cases. In hospital 98 days (France 17). Non-penetrating wounds 6 cases. In hospital 80 days (France 12). Haemothorax and pneumothorax cases not operated on in France or England. 167 cases. In hospital 82 days. Aspirated 73 cases. In hospital 88 days (France 16). Not aspirated 94 cases. In hospital 80 days (France 15). Penetrating ivounds without haemothorax not operated on in France or England. 58 cases. In hospital 62 days (France 14). Non-penetrating wounds. 18 cases. In hospital 58 days (France 16). These figures probably represent the averages for a much larger number of cases, but it will be noted that the proportion of empyema cases is low, namely 9-6 per cent, of the total as compared with 11 per cent, in the whole series. This of course is due to the fact that these cases remain much longer in hospital, and consequently fewer have as yet been discharged. Thus the average of 92 days for all classes of case is probably too low. These figures may be compared with those collected by Col. T. E. Elliott, A.M.S., and published in September 1917. 49 septic cases (empyema) in his series remained in hospital 7-3 months on an average. In the present series 31 cases remained 6-5 months. 75 haemothorax cases in Col. Elliott's series remained in hospital 3-8 months, 167 haemothorax cases in the present series remained in hospital 2-7 months. In 1917 Col. R. D. Rudolf published a series of 35 cases, with an average of 20 weeks in hospital (= 140 days), and in 1916 the Statistical Department of the Medical Research Committee traced 19 cases observed by me in France who were returned to duty or furlough in an average of 12 weeks. Putting these three series together, Elliott's cases (124) average 21 weeks Rudolfs cases (35) 20 Brickdale's cases (19) 12 ,, (178) 18 as against 92 days in the present series. This means a reduction, of about 1 month in the time spent in hospital, whether the comparison is made between the total cases, or in the septic and haemothorax cases separately. 6 III. DISPOSAL or CASES. 1. Empyemas. In 31 cases 18 cases were discharged to duty, employment, or Command Depot. 10 were discharged unfit (one owing to fractured humerus). 2 died. 1 returned to hospital for fractured arm. 2. Intrathoracic operations (excluding empyemas). In 21 cases 17 cases discharged to duty or Command Depot. 4 cases discharged unfit (3 for causes not connected with chest wound). 3. Excision of wounds. (a) Penetrating. In 23 cases 22 discharged to duty, employment, or Command Depot. 1 discharged unfit. (b) Non-penetrating. 'i 6 cases, all discharged to duty or Command Depot. 4. Haemotkorax and pneumothorax. () Aspirated. In 73 cases , A ; 70 discharged to duty, employments, or Command Depot. 3 discharged unfit (1 foreign body in heart, 1 adherent pericardium, 1 recurrent effusion into pleura), (6) Not aspirated. In 94 cases 91 discharged to duty, employments, or Command IJepot. 3 discharged unfit (1 foreign body in pericardium, 1 probably for rheumatism, 1 for fractured humerus). 5. Penetrating wouvids without haemothorax. 58 eases, all discharged to duty, employments, or Command Depot. 6. Non-penetrating wounds. 18 cases, all discharged to duty, employments, or Command Depot. Thus in 3.24 cases of all classes, 300 (nearly 90 per cent.) were discharged to duty, employments, or Command Depot, 21 (6 per cent.) were discharged unfit, of which 6 had other serious dis- abilities, 2 died, and 1 was returned to hospital for further treatment of fractured arm. IV. ULTIMATE RESULTS. It was possible to trace the ultimate results in the case of 106 patients in most cases from information kindly supplied by Dr. Matthew Young of the Statistical Department of the Medical Research Committee. 72, or 68 per cent., were returned to duty 12, or 11 per cent., to employments, 20, or 18 per cent., were discharged unfit (including 10 empyemas), and 2 died. These figures do not, of course, represent the ultimate fate of the whole series, because in the first place the proportion of empyemas is too high, and in the second place severely wounded men are discharged directly from hospital whereas those likely to be fit for foreign service go to Command Depots, the returns from which are not immediately available. There is reason to believe that only very lew of those sent to Command Depots from the Centre or from Convalescent Hospitals have failed to qualify for service either abroad or in the United Kingdom. Further analysis of these results shows : Class I (empyemas). 1 serving in United Kingdom. 1 discharged to duty with R.E. Railway Section, but found unfit after 2f months. He had a fractured arm. 2 were discharged to employments. 7 discharged unfit. 1 died. Class II (cases operated on in France). Division (i) intrathoracic operations. 1 serving with B.E.F. 1 classified A 3. 01. 2 discharged to duty, classification not known. 1 discharged to employment. 2 discharged unfit (1 empyema). Division (ii) excision of wound only. 1 classified A 1. 1 serving in United Kingdom. 1 classified B. 1 discharged to duty, classification unknown. 1 discharged to employment. 1 discharged unfit (empyema). 1 died. 8 In Class TIL 27 serving with B.E.F. or classified A 1. 30 serving in United Kingdom. 2 sent to Australia, classified B 2. 2 discharged to duty, classification unknown. 3 discharged to employment. 6 discharged unfit. V. EFFECTS OF BULLETS AND SHELL FRAGMENTS. The following tables show the effect of various projectiles in 542 cases. The empyemas have all been grouped together, and the other classes include only non-septic cases. Non-penetrating wounds have not been included in these tables. It will be seen that there were 319 bullet wounds compared to 209 shell fragment wounds, but that the number of empyema cases in each was equal. This means that shell fragments produced an empyema in 16-2 per cent., and bullets in 10-3 per cent, of the cases. 54 per cent, of shell fragments were retained in the chest, and of these 14 per cent, produced an empyema ; 26 per cent, were not retained, and of these 18 per cent, produced -an empyema. 11 per cent, of bullets were retained, and of these 16 per cent, produced an empyema ; 70 per cent, of bullets were not retained, and of these 9 per cent, produced an empyema. The order therefore of frequency in which the four classes stand is : Shell fragments, not retained . . . . 18 % empyemas. Bullets, retained 16 % Shell fragments, retained 14 % Bullets, not retained ...... 9 % If to the projectiles not retained be added those removed, the percentages of empyema cases work out at identical figures, probably because in the great majority of cases the projectiles are removed from the chest wall after traversing the thorax, and these wounds are therefore pathologically perforating in most cases. The comparison may be made clearer by the following scheme : In 100 wounds 60 bullet wounds 40 shell fragment wounds / \ / \ 6-6 retained 43-4 not retained 21-6 retained 18-4 not retained | or removed or removed I ^ ^ I 1-0 3-9 3-0 3-3 empyemas empyemas empyemas empyemas Thus, though in this series the actual numbers in the four classes with one exception are closely approximated, shell frag- ments are seen to be much more likely to cause empyema than bullets, but bullets when retained both relatively and absolutely give rise to fewer empyemas than any other class, though the retention of the projectile does not make much difference in the case of shell fragments. Empyemas Intrathoracic operations Excision of wound only . Haemothorax Penetrating wounds with- out haemothorax 9 TABLE III Shell fragments. Bullets. Bombs. Undetermined. 1 w 'i *? I | -S is e * 1 * 1 1 i .3 "S I J C i S ** K '8 i 1 ft! ^ ftl ef '< fp 2| '^ 4 "<5 ^o S 1& 10 8 6 22 6 i - , 5 12 11 8 9 5 I i 2 7 11 W 5 1 I \ i f>3 1& 12 21 43 31 4 1 1 _ "20 (5 1 42 8 1 i TABLE IV. Shell fragments. Bullets. - a 1 1 1 ^ 'S 1 1 C 1 ^ | :S fe; ( 5 tei $ Empyemas 16 10 8 G 21 Q All penetrating and per- ) forating wounds \ 23-8% 96 11-*% 45 14.9% 34: 8-9% 31 31-3% 205 8-9% 49 20-8% 9.7% 7.3% 6.7% 44-5% 10.6% VI. EMPYEMAS. The results in treatment of empyemas are presented here under three headings. (1) Primary empyemas opened in France, without previous operation on the lung (Class I in the series). (2) Empyemas occurring secondarily after thoracic operations in France (Class II in the series). (3) Empyemas opened after admission to the Centre, primary or secondary to thoracotomy (included in Class III in the series). (.1) Primary Empyemas. Of these there were 40 cases ; 22 were still in auxiliary conva- lescent hospital or had been transferred to Australian or Canadian hospitals at the time this report was written, 17 were finally disposed of to duty or Command Depot, or had been discharged unfit, and one died. The results as regards the function of the lung are classed as : (a) (rood, where the physical signs have cleared up completely and there is good expansion of the chest and little or no deformity. A 3 10 (b) Fair, where there are still physical signs in the chest, but fair expansion and not much deformity. (c) Poor, where the physical signs are still well marked, and expansion poor, with or without much deformity of the chest. The bacteriological findings are noted in the synopsis of cases whenever they had been determined. There is a general preva- lence of streptococci, either alone or with other organisms. In those in which the empyema was opened at a later date staphylo- cocci and other organisms were more commonly found. The larger number of cases were apparently simply opened and drained. Any further methods of treatment are noted in the synopsis whenever they were recorded on the field medical cards. In the case of secondary empyemas, the primary operation was performed within 24 hours, unless otherwise stated. The following figures refer to the whole number of cases, as far as the results could be ascertained. In 27 cases a good functional result was observed, on an average in 4-3 months ; in 19 cases a fair functional result in an average of 4-4 months ; and in 10 cases a poor functional result in an average of 7-8 months. Of the remaining 24 cases, 2 died, and in 22 the functional result could not be observed. In the first group (good), 65 per cent, were opened and drained within the first fortnight, and 22 per cent, within the second fortnight. In the second group (fair), 52 per cent, were opened and drained within the first fortnight, and 31 per cent, within the second fortnight. In the third group (poor), 23 per cent, were opened and drained within the first fortnight, and 7 per cent, within the second fortnight. Stated in another way : In cases drained during the first fortnight 56 per cent, gave good functional results, 3 per cent, fair, and 10 per cent poor. In cases drained during the second fortnight 45 per cent, gave good functional results, 45 per cent, fair, and 10 per cent, poor. In cases drained later than the second fortnight, 25 per cent, gave good functional results, 45 per cent, fair, and 50 per cent, poor. Synopsis of Cases. 2-3 months after date of wound (5 cases). I (2). Drained 18th day, sinus healed in 2\ months, fair functional result. (An officer, transferred to another hospital owing to fractured leg, was still in hospital 1 year after wound.) (Streptococci.) I (23). Draihed 6th day, much bluod clot evacuated ; sinus healed, and good functional result in 2 months. I (28). Drained 14th day. Sinus still present in 2\ months, with persistent physical signs, but fair functional result. (Staph'ylococci, P. Welchii, B. sporoyenes.) 11 1 (34). Drained 14th day, and subsequently irrigated. Tube removed in 10 days. A small sinus still present, but very fair functional result in 6 weeks. (Anaerobes.) I (36). Thoracotomy 16th day, after four aspirations. Fluid blood evacuated and wound closed. Re-opened and drained 19th day. Further operation for improved drainage, 52nd day. Poor result in 2 months. 3-4 months after date of wound (9 cases). I (14). Drained 19th day, after one aspiration fluid blood. Carrel tubes removed in 7 weeks, sinus nearly healed and fair functional result 3 month*. Subsequently discharged to C. D. (Sterile.) I (3). Drained 9th day after one aspiration. Very long sinus 2 months later ; good functional result but sinus not quite closed in 4 months. C. D. Now serving in United Kingdom. (Streptococci, anaerobes.) I (8). Drained 4th day. Further operation 14th day, tube removed in 2 l months. Healed in 4 months with good functional result. Discharged to C. D*. (Streptococci, staphylococci, B. Welchii.) I (33). Drained 4th day, and F. B. removed from surface of lung. Operation for improved drainage in 3 months. Final result not known. (Streptococci, B. sporogencs, B. WeJchii.) I (35). Drained 4th day, 3 Carrel tubes. Syringed daily with chloramine T. Fair functional result in 3 months. Still in hospital with unclosed sinus where F. B. was removed from beneath sternum. 1 (39). Drained llth day. Carrel tubes. Daily wash out. Sinus healed and good functional result in 4 months. I (40). Drained 23rd day after 3 aspirations. Jaundice and bile-stained discharge through empyema. Sinus still present, moderately fair functional result in 4 months. I (43). Leaking wound stitched. Double baemothorax and haemo-peri- cardium. Latter resected, F. B. removed, wound closed, good result. Empyema on L. side subsequently drained 27th day. Very fair functional result in 34 months, pleural sinus healed. Still a small sinus over pcricardial wound. (Streptococci, staphylococci.) I (44). Drained 7th day after 2 aspirations. Wound healed and very fair functional result in 3 months. (Streptococci.) 5-6 months after date of wound (11 cases.) I (13). Drained llth day, good functional result in 51 months. C. D. I (21). Drained 8th day, severe secondary haemorrhage, good functional result in 5 months. C. D. I (16). Drained 3rd day. Tube removed in 2 months, good functional result in 5 months. C. D. (Anaerobes.) I (24). Drained 22nd day through wound. Resection and improved drainage 42nd day. Tube removed 5th month. Sinus healed and good functional result in 6 months. C. D. (Streptococci, pneumococci.) I (25). Drained 9th day. Small sinus but good functional result in 5 months. C.D. (Streptococci.) I (4). Drained 2nd day, severely ill, bedsores and anaemia on admission in England. Tube removed in 2x months, healed in 6 months, with some flatten- ing of chest but fair functional result. (Officer, discharged to C. D.) I (5). Drained llth day after one aspiration. Further resection for secondary haemorrhage. Good functional result and sinus healed in 6 months. One month later discharged to employment (clerk), owing to scar tissue which impeded arm movement. I (27). Drained 12th day, sinus healed and good functional result in 5 months. (Streptococci.) I (29). Leaking wound sutured. Drainage 29th day after one aspiration. Good functional result but sinus still present in 5 months. .1 (30). Drained 18th day. Only clotted blood removed. Operation fof improved drainage 101st day. Sinus healed and good functional result in 6 months. I (31). Drained 28th day; layer of lymph sponged off surface of lung. Onlj A 4 12 fair functional result and sinus still discharging in 5 months. (Streptococci, staphylococci.) I (32). Drained 38th day. Operation for improved drainage 102nd day. Poor functional result in 5 months. 6-10 months after date of ivound (11 cases). I (9). Drained 6th day, portions of necrosed ribs caused sinus to re-open. Sinus finally healed with good functional result in 7 months. (Anaerobes.) I (17). Drained 20th day after 4 explorations. Good functional result in 4 months, but sinus not healed in 8 months. (Streptococci, staphylococci.) I (19). Drained 13th day after 1 aspiration. Sinus practically healed, but poor functional result in 4 months. Scoliosis and large axillary scar limiting movements of arm in 8 months. (Staphylococci.) I (20). Twice aspirated, but not drained for 2 months (Palestine), severely ill. Sinus healed in 4 months. Poor functional result and much shoulder-drop in 8 months. (Pneumococci.) I (22). Localized empyema communicating with lung abscess drained 55th day after one aspiration and two explorations of pleura. Poor functional result and long sinus still present in 9 months. I (15). Drained 8th day. Fair functional result but sinus not quite closed in 10 months. (Streptococci.) I (6). Drained 31st day. F. B. removed from abscess in liver, severe secondary haemorrhage from liver ; subsequent discharge of bile through empyema. Fair functional result in 6J months, but some persistent physical signs, and very deeply adherent scar over lower ribs in 10 months. I (10). Drained through intercostal space (date not recorded) ; still a small sinus, pyrexia and poor functional result in 5 months. Signs of peritoneal effusion during 5th and 6th months. Resection and drainage ii. pleura (localized empyema), in 5| months. Pyuria. Very poor functional result and unhealed sinus in 10 months. (Staphylococci.) I (11). Drained 17th day, after 2 aspirations. Portions of necrosed rib caused re-opening of sinus, which finally healed with poor functional result in 11 months. (Streptococci, staphylococci.) Discharged in 11 months (2 cases). I (1). Drained 12th day. Sinus healed and good functional result in 31- months. Discharged to duty (R. E. railway troops), but after 2* months dis- charged unfit possibly owing to weakness of arm from fractured humerus (11 months). (Streptococci.) I (12). Mediastinal abscess drained 28th day (Mesopotamia). Rib resected and F. B. removed from lung 42nd day. Poor functional result, much chest deformity and shoulder-drop in 7 months. Scar adherent to ribs and poor expansion in 11 months. Discharged in 12 months (1 case). I (7). Drained 31st day after 4 aspirations. Re-opened and drained in 4J months ; wound healed but broke down again in 9 months. Fair functional result but flattening of R. chest in 12 months. Died (1 case}. I (18). Drained 28th day, washed out with saline. Bronchitis and pleurisy of opposite side. Temperature never quite fell to normal, and on 57th day rose to 103, falling just before death on 68th clay. P. M. large F. B. (shell casing) at bottom of empyema. Double empyema, 'septic bronchitis, and early peri- carditis. (Streptococci.) < Result unknown. I (38). Drained 3rd day, after one aspiration. Transferred to Dartford in 6 weeks. I (41). Drained 36th day, with removal of clots, one previous aspiration. Tube still in after 2 months, but functional result not known. (B. Wehhii, pneumococci.) 13 (2) Secondary Empyema& /Synopsis of Cases. (!) After intrathoracic operations (14 cases). 3 months after date of ivound. II (28). Pleura sutured, but haemothorax not cleared out. F. B. removed from shoulder. Empyeina drained 14th day. Many small shell fragments retained. Good result in 3 months Subsequently re-admitted for further treatment of partial fracture of humerus. (Streptococci). II (219). Wound excised, F, B. removed from pleural cavity. Subsequently twice aspirated, but clear fluid only drawn off. Wound discharged pus on 10th day. Drained. Good result in 3 months, but scar deep and adherent. II (34). Open pneumothorax, wound excised, fractured rib removed, pleura closed. Empyema drained 8th day. No F. B. Good functional result, but some flattening of chest in 3 months. Discharged later to Command Depot. II (76). Wound excised, fractured rib removed, F. B. removed border of lung. Haemothorax cleared out, wound closed. Subsequently aspirated 3 times. Empyema drained llth day. Fair result with some flattening of chest in 3 months. Discharged later to Command Depot. II (89). Operation 4th day. Wound excised, small haemothorax cleared out. No F.B. Subsequent attack of broncho-pneumonia. Empyema drained 36th day. Still discharging in 3 months, with much falling of chest and shoulder- drop. Staphylococci. Result will probably be only fair. More than 3 months after date of ivound. U (16). Operation 2nd day, wound excised, fragments of rib removed, haemo- thorax cleared out, wound closed. Empyema drained in 3 months. Sinus healed in 5 months, but again broke down in 6 months. Poor result in 7 months. Subsequently discharged unfit. II (21). Operation. 14th day. Thoracotomy. Pleura washed out with Eusol. Wound closed. Subsequently aspirated twice. Persistent sinus. Empyema drained in 2J months Poor result with much shoulder-drop and deformity of chest in 6 months. Discharged unfit. Cases still discharging pus 3 months after date of wound. II (80). Wound excised, fragments of rib removed, lung sutured, haemothorax cleared out, wound closed. 12th day wound broke down and empyema was drained. II (102). Wound (sucking), excised, fragments of rib removed, haemothorax cleared out, wound closed. Twice aspirated. 12th day empyema drained. No F. B. (Streptococci.) II (110). Wound excised, lung sutured, haemothorax cleared, wound closed. 14th day empyema drained. No F. B. (Streptococci, pneumococci.) II (111). Wound excised, F. B. removed from chest wall, haemothorax cleared out. Wound closed. Aspirated once, 17th day empyema drained. II (118). Operation 4th day: wound excised, fragments of ribs removed, wounds in diaphragm and liver closed, wound closed. 13th day empyema drained and irrigated, F. B. retained in chest wall. (Staphylococci.) 5 months after date of wound. II (83). Wound excised, fragments of rib removed. F. B. removed, haemo- thorax cleared out. 8th day wound leaking. Empyema drained with Carrel tubes. General pyaemic infection. Pneumonia and multiple abscesses. Amputation through thigh. No F. B. In one other case observations were only possible for 1* months. 1 1 (27). Operation : wound excised, fragments of rib removed, haemothorax cleared out, wound closed. 7th day empyema drained. F. B. retained, irans- ferred to Dartford. 14 (u) After excision of superficial ^vound only (9 cases). 2 months after date of wound. II (26). Wound excised and portions of rib removed on 1st day. Drained on 24th day. Wound healed with .fair functional result in 2 months (transferred to Wokiugham). II (95). Wound excised 1st day. Drained 29th day, pyogenic membrane removed, and pleura washed out with saline. Later, irrigation with Dakin solution and Flavine pack. Empyema still discharging, but fair functional result in 2 months. II (34). Wound excised and sutured 1st day. Drained 4th day. Tube removed 20th day. Healed and good functional result in 2 months, when discharged to C. D. 3 to 4| months afterdate of wound. II (6). Wound excised 1st day. Drained 14th day after one aspiration. Fair result 4i months, subsequently discharged to Labour Corps. (Streptococci). II (22). Wound excised 1st day. Drained 9th day. No note as to final condition, but fit for C. D. in 4 months. (Strepto-bacillus,) II (125). Wound excised and sutured 1st day. Drained 6th day. Tube removed 12th day, closed in 3 weeks. Good functional result in 3 months. 5 to 6 months after date of wound. II (35). Wound excised 25th day ; drained 45th day, healed in 3J months, some flattening and shoulder-drop but good functional result in 5 J months, C. D. II (11). Wound excised and ribs found to be fractured first day. Drained 31st day. Partial Estlander with excision of 3 ribs in 2| months, Carrel tubes. Small sinus, but fair functional result with flattening of chest in 6 months. (Transferred to Wokingham.) Died. II (13). Wound excised and F. B. removed from under skin on 4th day. Septic pleurisy with continuous pyrexia. Drained 33rd day after one aspiration ; no pus but only clear fluid evacuated. Died 52nd day. P.M. double strepto- coccal pleurisy, and abscesses in lungs. (Hi) Cases operated on after admission (1 cases.} III (416). Thoracotomy and closure 29th day. Blood and clot removed, (streptococci and B. pyocyaneus present). Good functional result in 3 months. Subsequently sent to Command Depot. Ill (107). Admitted 18th day after wound in back. Temperature normal till 21st day. Signs of fluid at left base. 25th day empyema discharged through wound. Resection and drainage. Fair functional result in 3 months. F. B. retained in lung. Subsequently discharged to Command Depot. HI (378). Pleuritic effusion becoming purulent (streptococcal). Drained 2| months after wound. Had been aspirated twice. Good functional result in 4|, months. ^Subsequently sent ^o Command Depot. Ill (118). 'Drainage 29th day. Very severe infection but empyema localized by adhesions. Good functional result in 5 months. Subsequently sent to Command Depot. Ill (106). Thoracotomy 35th day, clot and blood cleared out, wound closed. Drained 44th day. Flattening of chest but good functional result in 6 months. (Streptococci, staphylococci). Subsequently sent to Command Depot. Ill (275). Septic contralateral pleurisy. Aspirated once. Drainage 135th day. Severe infection with abdominal symptoms. Further operation for drainage in 7th month, when upper abdomen also explored without result. Empyema localized by adhesions. Poor functional result in 11 months. (Staphylococci). Ill (252). Thoracotomy 32nd day. Patient (Canadian) was transferred tu Dartford too soon for complete observation. 15 VII. EAELY OPERATIVE TREATMENT. Sixty-two cases occurred in the series in which an intrathoracic operation with excision of wounds was done during the first day or two in France, of which 14, or 22-5 per cent., subsequently developed an empyema. This percentage is of course higher than that of the whole series (11 per cent.), but must be considered satisfactory when it is remembered that these were selected cases which the surgeons who first saw them considered so likely to become septic that an operation was undertaken. Primary union of the superficial wound occurred in 29 cases, or 60 per cent, of those in which an empyema did not develop. In 9 the wound broke down, leaving usually a large granulating surface, and in 5 the superficial wound was drained. In 2 an abscess formed in the chest wall, and 2 were left open by the surgeon. In one partial primary union occurred. Jn 76 cases the external wound or wounds were excised, but no intrathoracic operation performed at the early stage. Fifty-six were penetrating wounds, and 9 of these (16 per cent.) developed subsequently an empyema, 10 did not develop a haemothorax ; 20 were non-penetrating wounds. The empyemas have already been considered in a previous section of this report, including one of the 10 cases without haemothorax which subsequently developed a general pyaemia and died. Of the 29 in which the pleura was not directly involved, in 8 the wounds healed by primary union, and in 2 there was partial primary union. Twelve were left open, packed or drained, and 7 after complete closure broke down, leaving a granulating surface. Of the 37 in which there was also a haemothorax (not including the empyemas), in 15 the wounds healed by primary union, and in 2 there was partial primary union. Six were left open, packed or drained, and 13 after complete closure broke down, leaving a large granulating surface. TABLE V. fe* I l bf II " Intrathoracic operations ..... 48 40 7^ Excision of external wound only With haemothorax ...... 37 30 81 15 50 Without haemothorax .... 29 17 60 Total ........ 114 87 76 52 60 It will be seen from the Table that complete closure was rather more often practised when the pleura had been explored and emptied at the operation, and that it was successful in a higher percentage of cases, as far as primary union is concerned. The retention of the haemothorax in the pleura seems, therefore, to have lessened the chances of primary union. 16 Unfortunately, the number of bacteriological investigations in this class is small. Thirty haemothorax cases in the two groups were examined, of which 21 were sterile and 9 lightly infected (30 per cent.). In the haemothorax cases in this class of both groups in which primary union occurred, 16 only were examined, 11 sterile and 5 lightly infected (31 per cent.). The actual infec- tion of the haemothorax, therefore, as far as these meagre figures can be supposed to show, does not seem to affect the occurrence of primary union. Again, in non-penetrating wounds' complete closure was still less frequently attempted, and primary union occurred in a smaller proportion of such cases. In many of these cases, however, the wound was very large and severe or involved the shoulder, so that drainage or packing the wound was necessary, and closure after excision was less likely to succeed. The synopsis of cases shows that of 37 cases in which the haemothorax was cleared out at the primary operation, in 9 a good result was observed within 1 month, in 9 within 2 months, and in 6 within 3 months. In 2 cases a good result was observed in 3J and 6 months respectively. In 65 per cent., therefore, the lung appeared to be completely restored within 3 months. In 8 cases a fair result was observed, but only 2 of these were kept under observation for more than 3 months, so that improve- ment possibly occurred later. One case, in which the result was only fair in 5 months, was subsequently found fit for Command Depot, and one observed for 5| months had pus cells in the pleural fluid aspirated. In two cases a poor result was obtained after 4f and 6 months respectively. In 5 cases the haemothorax was not apparently evacuated at the primary operation ; 2 showed a good result within a month, and one in 2 months, having subsequently been aspirated. One other case not aspirated did not clear up for 6 months. In the last case a fair result was obtained after aspiration in 2 months. In 6 cases there was no evidence of a haemothorax ; a good result was observed in less than a month in 4 cases, and in the remaining 2, in 2 and 3 months respectively. In all, therefore, good functional restoration of the lung occurred in 36 out of 47 l cases which were regarded in the early stage as potential empyemas. and in only 2 was the result, as regards the lung, poor. Synopsis of Cases. Haemothorax cleared out at time of operation. 1. Good result tcithin 1 month. (24) Operation: haemothorax cleared out. Foreign body retained. Good result in 3 weeks. (72) Operation : haemothorax cleared out, diaphragm and liver torn (suture), pleura subsequently aspirated, sterile fluid. Foreign body not retained. Good result in 1 month. 1 In one other case with haemothorax a good result was obtained, but the date is not at present clearly ascertained. 17 (104) Operation: haemothorax cleared out ; physical signs persisted. Foreign body not retained. Good result in 1 month. (113) Operation: haemothorax cleared out; lung bruised; pleura subse- quently aspirated. Foreign body not retained. Good result in 1 month. (115) Operation: large haemothorax cleared out; wound of diaphragm closed. Foreign body removed from chest wall. Good result in 1 month. (116) Operation: large haemothorax cleared out: lacerated lung sutured. Foreign body not retained. Good result in 1 month. (78) Operation : haemothorax cleared out ; wound in diaphragm closed ; pleura subsequently aspirated. Foreign body not retained. Good result in 1 month. (122) Operation: haemothorax cleared out; pleura subsequently aspirated (sterile). Foreign body removed from chest wall. Good result in 1 month. (138) Operation : haemothorax cleared out. Foreign body not retained. Good result in 1 month (transierred to orthopaedic section for other injuries). Good result within 2 months. (42) Operation: haemothorax cleared out ; physical signs persisted. Foreign body removed from chest wall. Good result in 2 months. (46) Operation : small haemothorax cleared out ; pleura subsequently aspirated several times. Foreign body removed from pleura. Good result in 1J months. ~i51) Operation: haemothorax cleared out; pleura subsequently aspirated (sterile). Foreign body removed from lung. Good result in 2 months (discharged unfit owing to ulnar paralysis). (74) Operation: haemothorax cleared out; wound of diaphragm sutured; physical signs persisted. Foreign body not retained. Good result in 2 months. (79) Operation : haemothorax cleared out ; physical signs persisted. Foreign body retained below diaphragm. Good result in 2 months. (105) Operation : haemothorax cleared out ; physical signs persisted. Foreign body not retained. Good result in 2 months. (47) Operation : baemothorax cleared out ; pleura subsequently aspirated (sterile). Foreign body removed from chest wall. Good result in 2 months. (24) Operation : small haemothorax cleared out ; pleura subsequently aspirated (streptococci and staphylococci present). Foreign body not re- tained. Good result in 2 months. (137) Operation: open pneumothorax, with small effusion, cleared out; subsequently aspirated. Foreign body not retained. Good result in 1 months. 3. Good result in 3 months. (51) Operation: very small haemothorax cleared out; physical signs per- sisted. Foreign body not retained. Good result in 2| months. (52) Operation: haemothorax cleared out; pleura subsequently aspirated (sterile). Foreign body removed from mediastinum. Good result in 2i months. (57) Operation : haemothorax cleared out ; wound in lung sutured ; pleura subsequently aspirated. Foreign body removed from chest wall. Good result in 3 months. (60) Operation: haemothorax cleared out; pleura subsequently aspirated (sterile). Foreign body removed from pleura. Good result in 2i months. Discharged unfit owing to old deformity of chest and bronchitis. (168) Operation: large haemothorax cleared out ; diaphragm wounded; spleen torn. Foreign body not retained. Good result in 3 months. (38) Operation: pneumothorax. Foreign body not retained. Good result in 3 months. Discharged unfit owing to other injuries. 4. Good result after 3 months. (75) Operation : haemothorax cleared out ; very septic wound ; pleura sub- sequently aspirated several times streptococci present). Foreign body removed from chest wall. Good result in 3 months. (29) Operation: haemothorax cleared out. Foreign body not retained. Good result in 6 months. A5 18 5. Fair result. (12) Operation : large haemothorax cleared out ; pleura subsequently aspi- rated (sterile). Result doubtful, classified A. (33) Operation : haemothorax cleared out ; wound in diaphragm sutured ; pleura aspirated (sterile). Foreign body removed. Fair result in 1 month. (73) Operation : haemothorax cleared out. Foreign body not retained. Fair result in 2 months. (93) Operation: small haemothorax cleared out ; wound in diaphragm closed. Fair result in 2 months. Foreign body not retained. (88) Operation : haemothorax cleared out ; pleura subsequently aspirated several times. Foreign body retained. Fair result in 2i months. (90 Operation: haemothorax cleared out; pleura subsequently aspirated without result Foreign bo>ly removed from pleura. Fair result in 2^ months. (39) Operation: haemothorax cleared out; wound in diaphragm closed; physical signs persisted. Fair result in 5 months. Foreign body removed. Ultimate disposal, C. D. (62) Operation : haemothorax cleared out ; subsequently aspirated and pus cells found. Foreign bodies retained. Fair result in 5J months. 6. Poor result. (56) Operation : haemothorax cleared out ; spleen lacerated (drainage) ; large pneumo-haemothorax subsequently aspirated (streptococci). No foreign body. Poor result in 4i months. (19) Operation: large haemothorax cleared out; pleura subsequently aspi- rated. Foreign body present close to heart. Poor result in 6 months. Cases in which there is no record oftJie treatment of the Haemothorax. (2) Small haemothorax subsequently aspirated. No F. B. (rood result in 2 months. (63) Operation : pleura closed, and subsequently aspirated. Foreign body retained. Good result in 1 monih. (77) Operation : pleura closed, and subsequently aspirated. Foreign body not retained. Prolonged sub-acute broncho- pneumonia. Good result in 1 month. (59) Operation: pleura closed. Foreign body removed from pleura. Physical signs persisted. Good result in 6 months. (64) Operation : pleura closed ; subsequently aspirated (sterile). Foreign body retained. Fair result in 2 months. Cases in tchiih there was no evidence of a haemothorax. (37) Operation : pleura closed. Foreign body removed from pleura. Much atrophy of shoulder giidle muscle*, due to wound through shoulder. Good result in 2 weeks. (120) Operation : pleura closed. Foreign body removed from chest wall. Good result in 3 weeks. (109) Operation: pleura closed. Foreign body not retained. Good result in 3 weeks. (58) Operation: pleura closed. Foreign body removed from diaphragm. Good result in 1 month. (100 Operation: pericardium exposed. Foreign body removed ; pleura and pericardium closed. Very septic wound. Good result in 2 months. Other seveie wounds. Femoral thiumbosis. (15; Ojeiation: liver explored; abscess drained; subsequpnt pleural effu- sion aspirated. Foreign body not retained. Good result in 3 mouths. The synopsis of haemothorax cases in which the external wound was excised shows that out of 32, a good result occurred within 1 month in 10, within 2 months in 8, and within 3 months in 3. In 3 more it was noted in 4 months. Thus, as in the previous group, a good result within 3 months was obtained in 65 per cent. Of the cases. 19 In 4 cases a fair result was noted within 2 months, and these may have improved later. In one case there was a fair result only in 3 months. In the 3 cases in which only a poor result could be recorded, the observation did not extend beyoLd 2 months. Synopsis of Cases. Haemothorax with excision of external wound. Good result within 1 month. (8) Wound excised : fragments of scapula removed ; haemothorax very small and not aspirated, wound granulating. G >od result in 1 month. (9) Wound excised and closed ; no injury to ribs; haemothorax very small and not aspirated : primary union. Good result in 18 days. (17) Wound excised ; fractured ends of ribs removed ; haemothorax small and not aspirated ; primary union. Good result in 14 days. (53) Wound excised and closed ; haemothorax very small and not aspirated; wound granulating. Good result in 18 days. (55) Wound excised and drained ; haemotborax aspirated. Good result in 1 month. (57) Leaking wound excised and closed ; haemothorax not aspirated ; primary union. Good result in 1 month. (87) Wounds excised ; loose pieces of bone removed ; aspirated twice ; partial primary union. Good result in 14 days. (121) Wounds excised and closed; haemothorax not aspirated; wounds granulating. Good result in 1 month. (123) Sucking wound excised; fragments of rib removed; wound closed; haemothorax aspirated ; primary union. Good result in 1 month. (133) Wound excised and F. B. removed ; wound left open ; haemothorax not aspirated. Good result in 1 month. Good result in 2 months. (14) Wounds excised and closed ; haemothorax aspirated ; primary union. Good result in 1| month. (30) Wound excised and left open ; haemothorax not aspirated. Good result in li month. (32) Wound excised and packed ; pleura found punctured ; F. B. removed from chest wall ; small haemothorax not aspirated. Good result in li month. (48) Wound excised and closed ; haemothorax not aspirated ; wound granu- lating. Good result in 1-|- month. (106) Wound excised ; "F. B. removed from rib ; wound closed ; haemothorax not aspirated ; wound granulating. Good result in 1| month. (10) Wound excised and closed ; haemothorax not aspirated. Good result in 2 months. (25) Wound excised, exposing pericardium ; no pericarditis ; wound closed ; haemothorax aspirated ; wound granulating. Good result in 2 months. (28) Wounds excised and closed ; haemothorax aspirated ; primary union. Good result in 2 months. Good result in B months. (41) Wound excised ; fragments of rib and scapula removed ; wound closed ; haemothorax aspirated ; primary union. Good result in 2| months. (103) Wound excised ; fragments of ribs removed ; pleura not open ; haemo- thorax not aspirated ; partial primary union. Good result iu 2J months. (7) Wounds excised and closed ; very small haemothorax not aspirated ; primary union. Good result in 3 months. Good result in 4 months. (45) Wound excised and closed ; haemothorax aspirated. Good result in 3 months. (136) Entrance wound excised and .closed ; primary union ; exit wound excised and drained ; haemothorax not aspirated. Good result in 3 months. 20 (82) Wounds excised ; F. B. removed from region of 'scapula ; wound closed ; haemothorax aspirated ; wound granulating. Good result in 4 months. Fair result. (101) Wounds excised ; F. B. removed ; track drained ; haemothorax not aspirated. Fair result in 1^ months. (112) Wound excised and left open; haemothorax twice aspirated. Fair result in 1 month. (92 Wound excised and closed; fragments of rib removed; haemothorax aspirated ; abscess formed in chest wall. Fair result in 2 months. (135) Entrance wound excised and closed; exit wound drained ; haemothorax not aspirated. Fair result in 2 months. (79) Wound excised and closed ; haemothorax not aspirated ; wound granu- lating. Fair result in 3 months. Poor result. (91) Wounds excised and closed ; haemothorax aspirated twice ; primary union. Poor result in 1 month. (128) Wound excised and closed ; haemothorax aspirated ; primary union. Poor result in 2 months. (130) Exit wound excised ; entrance wound drained ; F. B. removed and exit wound closed, with primary union ; haemothorax not aspirated. Poor result in 2 months. In 5 cases the result was not ascertained. Penetrating wounds without haemothorax. (4) Wound excised but not closed, and F. B. removed. No physical signs in 10 days. Discharged to Command Depot in 2 months. (18) Wound excised and closed ; F. B. not retained ; primary union. Patient suffered from dilatation of the heart, but was discharged fit for General Service in 2^ months. (20) Wound excised, but did not heal by primary union ; considerable dry pleurisy. The large scar resulting impeded arm movements, and he was dis- charged unfit in 2\ months. (36; Wound excised, but broke down ; large granulating surface ; F. B. not retained ; signs of considerable haemorrhage into lung, and subsequent muco- purulent bronchitis. The case was complicated by an attack of jaundice (toxic) and considerable muscular atrophy. Discharged to employment in 6 months. (49) Wound excised ; healed by granulation ; F. B. removed from chest wall ; dry pleurisy. Discharged to Command Depot in 2 months. (71) Wound excised and drained ; damage to head on humerus ; F. B. re- tained in mediastinum ; no physical signs in lungs. Transferred to Wokingham. (99) Wound excised and partially closed ; signs cf haemorrhage in the base of R. lung. Transferred to Dartford in 3i months, with a small sinus still present. (119) Wound in back with fracture of dorsal lamina; wound excised ; bone and F. B. removed ; wound drained. No return as yet as to final condition. (13) This case which subsequently died is included among the empyemas. TABLE VI. Group 1. Under 3 months. Over 3 months. Good 24 2 Fair 5 Poor 2 Group 2. Under 3 months Ovev 3 months. Good 21 3 Fair 5 Poor * 3 21 The table shows that, as far as the functional result to the lung* is concerned, the results are about equal ; the poor functional results are not comparable, but the good results in each amount to 65 per cent. The cases in the first group were presumably more severe and the pulmonary embarrassment more marked initially than was the case in the second group ; this, and the fact that a larger proportion of primary unions was secured, is remarkable testimony to the success of the surgeons who performed the early operations. VIII. HAEMOTHOBAX. (1) Results of aspiration. Of the 292 haemothorax and pneumo-haemothorax cases com- prised in Class III of this series, 138 were aspirated either before or after their admission to the Centre. The time occupied by the lung in regaining its functional activity was ascertained in 167 cases. In others the final result, though known, was not accurately timed, as the patients were transferred to auxiliary hospitals or to hospitals for overseas troops. In others again a fair or poor result was recorded. The haemothorax cases are in the following table divided into large and small. In the aspirated cases, all in which 30 ounces or more were evacuated at a single time are classified as large, and the rest as small. In the non-aspirated cases, all giving physical signs of fluid reaching into the axilla and up to the spine of the scapula, with more or less displacement of the heart, are classified large, and the rest small. The table shows the number of cases in which a good result occurred in each class, and the number of months from the date of wound. Large haemothorax not aspirated . Large haemothorax aspirated . . . Small haemothorax not aspirated . . Small haemothorax aspirated TABLE VII. Months. 12345 19711 10 11 3 1 48 32 4 3 14 18 5 Total. 19 25 87 37 This table shows that 42 per cent, of the large non-aspirated cases gave a good result in 2 months or less, and 84 per cent, of the large aspirated cases ; 91 per cent, of the small non-aspirated cases gave a good result in 2 months or less and 86 per cent, of the small aspirated cases. Aspiration therefore appears to have hastened functional recovery of the lung in the large haemothorax cases, especially as the non-aspirated cases on the whole were probably smaller than the aspirated ones. 22 In the case of small haemothorax, the non-aspirated cases seem to recover more quickly ; this is probably because on the whole the aspirated cases were larger effusions. In the following tables an attempt is made to show the value of early and complete evacuation of the large effusions. All cases are included, and not only those which could be followed up to a final result. Haemothorax aspirated 30 ounces or more. I, Aspirated during the first week. Good result in 3 weeks III (288) 3rd day 5 50, 7th day 5 70 III (327) 3rd ,,352 . Ill (388) 2nd 36 ' [ -.\< III (123) 1st week 30 . Ill (264) 4th day 5, 5th day 35 Ill (126! 5th III (306) 4th III (115) 2nd III (39) 3rd III (266) 2nd 52 4. 6th day 30 30 . 36 . . 38, 5th day 24 a M 3 4 Fair result in 4 Good result in 5 8 12 months II. Ill (393) 12th day 46 III (224) 5th III (77) 10th III (124. 7th III (294) 14th Aspirated dwiny the first 14 days. Good result in 3 weeks 36, 8th day 40 30 . . . 3, 9th day 30 ., 12 Fair result in 3 111. Cases aspirated during the first 23 days. III (295) 3rd day 8, 16th day 32 '. * '-.-. Ill (234) 12th 4, 23rd day 35 III (218) 19th 38 . . . . - . ' . Ill (278) 16th 130 Ill (399) 1st ,. 18, 15th day 37 . 111(415) 6th ., 30, llth 12, 22nd day 20 III (382) 8th 46, 22nd 46 . Ill (417) 18th 42 Ill (28) 12th 49, 16th day 14 . Ill (132) 3rd 35, 4th 14, 6th day 7, 20th ,, 5 Ill (162) 4th 30, 17th day 17 . Poor result in 4 Good result in 4 6 6 6 . 6 Poor result in 8 Good result in 10 Fair result in 10 Poor result in 10 ,, Good result in 5 months IV. Cases not aspirated for the first time till the 21st day or later. Ill (245) 21st day 30 . Good result in 4 weeks III (199) 22nd 57 III (328) 34th 41 III (343) 34th 39 III (242) 24th 31 .. 6 7 7 Fair result in 10 Taking only those cases in which a good result was obtained, the following summary shows the advantage of early evacuation of a large haemothorax. /. Aspirated during the first week. 10 cases, average amount withdrawn at one or more aspirations 49. Eight cases (80 per cent.) showed a good result in an average of 5^ weeks. 23 //. Aspirated during the first fortnight. 5 cases, average amount withdrawn at one or more aspirations 43. 4 cases (80 per cent.) showed a good result in a'n average of 7 weeks. III. Aspirated during the first 23 days. 1 1 cases, average amount withdrawn at one or more aspirations 560. 6 cases (54 per cent.) gave a good result in an average of 1\ weeks. IV. Cases not aspirated till 2lst day or after. 5 cases, average amount withdrawn 39. 4 cases (80 per cent.) gave a good result in an average of 6 weeks. It will be noted that the amount withdrawn in the last group was smaller than in the first three. One other aspirated case was exceptional, as the effusion recurred; that is, a recurrent serous pleurisy was set up. The details are given below in the synopsis of cases (III. 102). Haemothorax cases aspirated, from 15 to 30 ounces. I. Cases aspirated during first iveek. III (232) 2nd day 20 . 111 (309) 7th ,, 22 ... , III (317) 1st 22 III (394) 7th 24 . III (406) 7th 22 . ( -. . . . III (202) 4th 26 . III (163) 4th 15 . III (325) 3rd 20 III (35B) 2nd 16 . '. III (389) 3rd 22 . 111 (136) 2nd 8, 6th day 15 . 111 (178) 3rd 12.6th 9 . .,, ., . III (151) 3rd 5 27 . . 111 (153) 6th 18 . . . .:: ..... > 111 (418) 5th 20 . III (358) 7th , 20 III (42) 3rd , 32> , III (101) 7th 5 26 III (289) 1st o u J 522 III (315) 4th ' \ 18 111 (396) 3rd 1 5 28 . . Good result in 2 weeks 4. > > M 4 ;; Fair result in 4 . ,, 4 Poor result in 4 Good result in 5 ^ 6 6 8 ,, 8 Poor result in 8 8 10 //. Cases aspirated during first fortnight. III (281) 3rd day 17, 9th day 13 III (25) 10th , 24 . 26, llth day 4 22 . 18 . . . Ill (271) 7th III (381) 15th III (375) loth III (311) 8th III (80) 13th III (395) 4th 15 Fair result in Good result in Fair result in " " Good result in Fair result in 2 weeks 3 6 6 7 7 s 20 Good result in | 25, 9th day 17 , , . Poor result in 24 III. Cases aspirated during first 28 days. Ill (24) 2nd day 3 15, 18th day 3 6 . . Good result in 3 weeks III (70) 3rd f) 21, 15th day 5 18 ... ,,4 III (253) 17th 3 21 . . . . . . Fair result in 4 III (252) 19th 3 27 4 III (144) 18th 3 18 Good result in 5 111(361) 2nd ,, g 21, 28th day 3 21 . .. . ,, 5 III (139) 18th g 20, 25th 12 ... 6 III (172) 16th 20 . ... 8 III (258) 10th 20, 17th day 3 22, 22nd day 5 5 8 IV. Cases not aspirated till the 21st day or later. Ill (366) 21st day I 26 III (159) 21st 27 III (129) 22nd III (348) 23rd III (212) 24th III (221) 25th III (308) 25th 5 20 . . . 3 20, 27th day 3 22 328 . 328 . Good result in 6 weeks Poor result in 12 Good res It in 8 Poor result in 8 Good result in 10 ,. 12 Fair result in 7 Ill (307) 45th ., 5 22 . Summarized, these cases show that recovery of the lung was delayed in cases not aspirated before the 21st day, though the first 3 classes took on an average about the same number of weeks for recovery. /. Aspirated during th". first week. 23 cases, average amount withdrawn at one or more aspirations 13 cases (56 per cent.) showed a good result in an average of 5 weeks. II. Aspirated during the first fortnight. 8 cases, average amount withdrawn at one or more aspirations 3 25. 3 cases (37 per cent.) showed a good result in an average of 6 weeks. III. Aspirated during the first 28 days. 9 cases, average amount withdrawn at one or more aspirations 5 28. 7 cases (77 per cent.) showed a good result in an average of 5-5 weeks. IV. Not aspirated till 21 si day or later. 8 cases, average amount withdrawn at one or more aspirations 3 26. 4 cases (50 per cent.) showed a good result in an average of 9 weeks. 14 cases were aspirated to amounts varying between 3 5 and 5 15 during the first 18 days, the average being 3 9 ; none were aspirated more than once. 10 cases (71 per cent.) showed a good result in an average of 6 weeks. The next Table (VIII) shows the number of weeks which elapsed before the physical signs in the lung cleared up in 168 cases, and brings out the advantage of aspirating the large 25 I I eo 2J cc O .- * I o CO *< . ~ 6D - I? I II ! S ~ ^ < S.'S. -w C> 'S tJO O 60 K 3 s S * 3-2 s ta 26 haemothorax. The small haemothorax clears up well in any case, but the aspirated cases, as noted above, were probably larger than those not aspirated. Synopsis of 34 large haemothorax cases (aspirated). 1. Cleared iip in 1 month or undo: III (123). Shell fragment penetrating chest, F. B. apparently not retained. Aspirated 30 ounces within first week. Aspirated again 9th day air only. Pericardial effusion which cleared up in 14 days. Admitted 21st day, with slight physical signs. No F. B. by X-ray. Good result in 4 weeks. Ill (224). Shell fragment, F. B. retained in R. chest. Aspirated 5th day 386, 8th day 40 (sterile). Admitted 14th day. Diaphragmatic adhesions shown by X-ray 19th day. Good result in 4 weeks. Ill (245). M. G. bullet perforating L. chest. Admitted 14th clay. Aspirated 5 30 mixed with air on 21st day. Good result in 4 weeks. Ill (264). M. G. bullet perforating R. chest. Aspirated 4th day 5 5, 5th day 5 35 (sterile). Admitted 14th day. Slight physical signs for 4 weeks. Probably residual clot. Ill (288). Bullet perforating R. chest and retained in muscles of back. Aspirated 3rd day 5 50. (Sterile) 7th day 3 40. Admitted 12th day. Good result in 3 weeks. Ill (306). Shell fragment, penetrating L. chest. Aspirated 5th day 3 4, 6th day 3" 30. Admitted 19th day. Good result in 4 weeks, but still slight physical signs, which had cleai-ed up completely when patient was discharged to Command Depot. Ill (326). Rifle bullet perforating R. chest. Aspirated 3rd day 3 52 (sterile). Admitted 8th day with slight physical signs and X-ray shadow. Good result in 3 weeks. Ill (388). Rifle bullet perforating chest. Aspirated 2nd day 3 36 (sterile), 4th day explored without result; admitted 23rd day with no physical signs or symptoms. Ill (234). Shrapnel bullet, penetrating both chests and lodged near heart. L. haemothorax small and not aspirated. R. haemothorax aspirated 12th day 4; admitted 15th day with signs of bronchitis L. side. Moderately large haemothorax R. side, with displacement of heart, confirmed by X-ray. Aspirated 23rd day 5 31 (sterile). Good result in 4 weeks. Ill (393). M. G. bullet perforating R. chest. Admitted 10th day, with signs of moderately large haemothorax, but without displacement of heart (confirmed by X-ray). Aspirated 12th day 46 (infected). Good result in 3 weeks. 2. Cleared up in 1 to 2 months. Ill (77). Multiple small shell fragments penetrating L. chest, some of which were retained in lung. Aspirated 10th day 40 (sterile). Admitted 22nd day with slight physical signs confirmed by X-ray. Good result in 2 months. 111(115). Bullet perforating chest. Aspirated 2nd day 3" 30. 14 days' fever. Admitted with well-marked physical signs 21st day. Good result in 2 months. Ill (126). Shell fragment perforating R. Chest. Aspirated 5th day 52 (sterile). Admitted 36th day, no physical signs or X-ray shadow ; but movement not good till 8th week. Ill (199). M. G. bullet perforating R. chest. Admitted 19th day with signs of large haemothorax (confirmed by X-ray). Aspirated 22nd day | 57, with much air. Good result in 6 weeks. Field medical card stated that there were signs of a small haemothorax on 12th day, so that there must have been either considerably more haemorrhage after that date, or a serous effusion. The general condition of the patient on admission pointed to latter explanation. Ill (218). M. G. bullet perforating L. chest. Admitted 13th day with signs of moderately large haemothorax without displacement of heart (confirmed by X-ray). ' Aspirated 19th day 3 38 (infected). Good result in 6 weeks. Ill (228). M. G. bullet perforating L. chest. Admitted 13th day with signs of good-sized haemothorax (confirmed by X-ray). Aspirated 20th day 5 31 (infected). Good result in 6 weeks. III (278). Shell fragment penetrating L. chest. No exit wound, but F. B. not seen by X-ray ; admitted 10th day with signs of large pneumo-haemotborax and displacement of heart (confirmed by X-ray). 16th day aspirated 130 (sterile). Good result in 6 weeks. Ill (328). Shell fragment perforating L. chest. Admitted 19th day with signs of moderate-sized haemothorax without displacement of heart, (confirmed by X-ray), 34th day, aspirated 3" 41 (sterile). Good result in 7 weeks. Ill (343). Rifle bullet perforating R. chest. Admitted 19th day with signs of good-sized haemothorax with cardiac displacement (confirmed by X-ray). Aspirated 34th day 5" 39 together with air. Good result in 7 weeks. Ill (415). Rifle bullet perforating L. chest. Aspirated 6th day 5 30 (sterile), llth day 3 12. Admitted 17th day with signs of moderate-sized haemothorax with displacement of heart,, confirmed by X-ray, 22nd day aspirated 3 20 (sterile) with air. Good result in 6 weeks. 111(399). Rifle bullet perfo rating L chest. Aspirated 2nd day 3 18. Admitted 12th clay with signs of good-sized haemothorax with displacement of heart (confirmed by X-ray). Aspirated 15th day 3 37 (sterile). Good result in 6 weeks. 3. Cleared up in 2 or 3 months. 111(39). M. G. bullet perforating R. chest. 3rd day aspirated 3 36. Admitted 15th day with signs of small haemothorax in R. axillary region and some displacement of heart (confirmed by X-ray which also showed diaphragmatic adhesions). Friction-sound heard at R. base in 6th week. Good result in 2J months. Ill (124). Rifle bullet perforating R. chest. Aspirated 7th day 3 3 (sterile), 9th day 3 30 (sterile). Admitted 23rd day with signs of a fairly extensive haemothorax, but without complete collapse of lung. Heart not displaced (confirmed by X-ray). Good result in 2|- months. Ill (417), Bullet perforating L. chest and removed from under skin of back, Admitted llth day with signs of moderately large haemothorax without displacement of heart (confirmed by X-ray). Aspirated 18th day 3 42 (sterile). Good result in 2J months. 4. Cases which did not clear up for more than 3 months. Ill (102). Rifle bullet retained in L chest, a little to L. of sternum, opposite 2nd rib. Aspirated 4th day 26. Admitted 15th day, very anaemic in appearance, with signs of a large haemothorax (confirmed by X-ray), and displacement of heart. Aspirated 10th day 3 70, sterile. Irregular temperature for 40 days. Physical signs cleared up to some extent, but lung did not expand well, in spite of physical exercises, and he remained dyspnoeic on slight exertion. Transferred to convalescent hospital in 2 months, and then again aspirated on 109th day 40, as the physical signs showed re-accumulation of fluid. (This was stated to be ' thick fluid ', but it is not clear whether it was altered blood or turbid serum.) In 6 months movement was very poor, the chest had fallen in, and the breath sounds at L. base were very faint. He was a man of poor physique, and was discharged permanently unfit. Ill (162). Shrapnel bullet penetrating L. chest, and removed from beneath clavicle. Aspirated 4th day 30, 17th day 7 (sterile). Fluid clotted imper- fectly. Admitted 31st clay, with signs of moderate-sized haemothorax without displacement of heart (confirmed by X-ray). Physical signs slight after 21- months, chest practically normal in 5 months. "Ill (266). Shell fragment penetrating lung. Aspirated 2nd day 3 38, 5th day 3 24. Admitted 19th clay with signs of a small haemothorax (confirmed by X-ray), which did not clear up for 4 months. 5. Cases in which the date of recovery of lung could not be determined. Ill (294). Rifle bullet perforating R. chest. Admitted 7th day, with signs of large haemothorax and displacement of heart (confirmed by X-ray). Aspirated 14th day 3 32 (sterile). Physical signs had not cleared up in 3 weeks. Trans- ferred to Dartford. Ill (295). Rifle bullet perforating L. chest. Aspirated 3rd day 5 8. Admitted 28 6th day, with signs of good-sized haeniothorax and displacement of heart (confirmed by X-ray). Aspirated 16th day 3 32 (infected). Temperature irregular till after 2nd aspiration. Heart normal in position, but physical signs in lung still present in 4 weeks. Transferred to Dartford. Ill (264). M. G. bullet perforating R. chest. Aspirated 4th day 5 5. 7th day 3 35 (sterile). Admitted 13th day, with signs of small haeniothorax, with- out displacement of heart (confirmed by X-ray). Physical signs less marked in 4 weeks. (Later reports not yet received.) Ill (382). Shell fragment penetrating R. chest. Signs of pericarditis and large haemothorax. Aspirated 8th day 5 46 (sterile) : 22nd day 3 46 (sterile). Admitted 33rd day, with signs of large haemothorax and displacement of heart. Explored 25th day, but only a little thick, dark-red fluid obtained (sterile). Still fairly extensive physical signs in_2 months. (Later report not yet received.) Ill (132). Shrapnel ball perforating L. chest, and removed from under skin in 2nd left space. Aspirated 3rd day 3 35, 4th day 5 14, 6th day 3 7 (with much air). Admitted 19th day, with signs of a large pneumo-haemothorax, and displacement of heart (confirmed by X-ray). Aspirated 20th day 3 5 with some air, 49th day explored without result. Physical signs well marked in 2^ months. Was subsequently discharged to Command Depot. Ill (28). M. G. bullet penetrating L. chest, and retained in front of 1st dorsal vertebra. Aspirated 12th day 5 49, 16th day 5 14 (sterile). Admitted 33rd day, with signs of a small haemothorax (X-ray showed a much greater extent of shadow than was to be expected from physical signs). Aspirated 46th day 5 2 only (sterile). Probably residual clot. Physical signs had not cleared up in 2^ months, but chest reported normal in 6 months. Ill (242). Rifle bullet perforating R. chest. Admitted llth day, with signs of good-sized haemothorax, but without displacement of heart (confirmed by X-ray). Aspirated 24th day 3 31 with air (infected). Physical signs persisted for 2J months, but thero were faint breath-sounds and good movement over the small area at the R. base and axilla. (Later report not yet received.) (2) Delayed absorption, of haemothomx. The following tables show the 'fair' and 'poor' results in haemothorax cases ; those in which the last observation was recorded during the first 4 weeks can hardly be considered, as they might well have cleared up completely in average time, but in the remainder some delay beyond the average is certain or probable. In 26 cases, therefore, there was some delay, and in 7 the delay was considerable. In the following synopsis the histories of 13 cases are given, in which, although there were signs of a fairly large haemothorax, attempts at aspiration were not successful. It seems probable that in these cases the haemothorax was partially clotted ; the functional recovery of the lung is as follows : Good result in 2 months 1. s, 3 ., 6. ., over 3 months 2. Fair result in 2 months 1. Poor JTUUi 3 1. Of these, therefore, only 1 showed a good result in the average time. I I g CO 2 I I * .-I I x M x ' 2.2.2. S '5. S p< -!-> O> &.Z2 ** " C. 30 In addition to the cases in the synopsis, there were 14 cases of small haemothorax in which aspiration was unsuccessful. These gave : Good result under 1 month 4. 2 months 5. 3 months 3. Fair 2 months 2. The dates of exploration are shown in the following table : TABLE XI. Large haemofhorax. Small haemothorax. 3rd day, later, and 21st day. 1st da}". 31st day. 3rd day. llth day, and 22nd day. 2nd day (2 cases). 6th day\ 12th day, and 36th day. 3rd day. 7th day, 35th day. 4th day and 23rd day. 10th day, 21st day. 10th day (3 cases). 17th day. llth day. 18th day. 12th day. 19th day. 13th day. 20th day. 14th day. 26th day (2 cases). 27th day and 34th day. 35th day. 29th day. 36th day. In the large haemothorax cases, 5 explored during the first fortnight cleared up in an average of 1 1 weeks, and 6 explored during the second fortnight cleared up in an average of 12 weeks. 11 of the small haemothorax cases explored in the first fortnight cleared up in an average of 6 weeks, and one of the 2 explored after the first fortnight cleared up in 10 weeks. Those, therefore, which appeared to become inaspirable early did not take longer to clear up than those in which the evidence of clotting was not obtained till later. The cell-counts in these cases varied considerably, but will be further considered in a subsequent section. The cells were too few to count differentially in 7 cases (10th, 14th, 18th, 19th, 21st, 36th, and 53rd days). In 9 cases cell-counts were possible, and were as follows : TABLE XII. Endothelial. Mononudear. Polynuclear. 13th day 50 30 20 1 6th 18th 2 21st '22nd 1 25th 33rd 34th 40 40 20 40 50 10 20 30 50 60 30 10 10 10 80 10 50 40 55 40 5 10 85 5 In 22 cases the fluid was examined for organisms either in France or England, 9 were found infected, and 13 sterile. This is equivalent to 41 per cent., a much higher percentage than that of haemothorax cases as a whole. 1 These cases also showed presence of organisms. 2 There were very few cells, and the figures are only approximate. 31 In a dozen such cases, the majority of which were still in hospital when this Eeport was written, and thus could not be included in the present series, the pleura had been opened. All but 2 were definitely infected, though not generalized empyemata. The pleura was found full of sticky gelatinous clot and flakes of fibrin with a variable amount of liquid. In some cases small masses of purulent material were found, and in others the fluid and clot were found to contain organisms when examined bacteriologically. Only 3 healed rapidly ; one died of general pyaemic infection. In some cases the temperature rose after the operation and only gradually fell as free drainage was established. In one the chest had to be opened a second time owing to re- accumulation of pus. It seems that clearing out an inaspirable lightly infected haemothorax tends to the formation of a definite empyema. Unless, therefore, the temperature shows that con- siderable septic absorption is already taking place, it may be wiser to leave these cases alone. Synopsis of cases of clotted haemothorax. Ill (75). Rifle bullet perforating R. chest. Explored, but not aspirated, in France. Admitted on 16th day, with pli3'gical signs of moderate R. haemo- thorax, with heart displaced. Aspirated on day after admission, only 3 obtained. Fluid sterile. Apex returned to normal position 25th day, but physical signs did not clear up for 2^ months. Ill (76). Rifle bullet perforating Tl. chest. Admitted 15th day, with signs of large haemothorax ; heart considerably displaced. X-ray confirmed findings. Aspirated 19th day, but only 14 withdrawn. Fluid sterile. Heart did not return to normal for 1 month. Physical signs did not clear up for 12 weeks. Ill (79). M. G. bullet perforating right chest and removed from under skin of back. Admitted 17th day, with signs of a large haemothorax and displace- ment of heart (confirmed by X-ray). Aspirated 20th day, only 4. Heart normal in position in 1^ months. Physical signs cleared up in 2 months, but movement still somewTmt impaired. Discharged to Command Depot in 3 months. Ill (84). M. G. bullet perforating R. chest. Admitted 9th day, with signs of good-sized haemothorax (confirmed by X-ray). Explored 18th day, but only 3 | withdrawn. Fluid sterile, with practically no cells. Physical signs not completely cleared up in 2 months. Ill (97). M. G. bullet perforating L. chest. 3 1 withdrawn on 7th day and found to be sterile. Admitted 20th day, with signs of large L. haemothorax, heart much displaced (confirmed by X-ray). Explored 26th day, only J ) \ with- drawn. Fluid contained staphylococci, a few B. pyocyaneus, and diphtheroid bacilli. Heart normal in position in 6 weeks, but physical signs had not cleared up in 3 months, and there was considerable falling in of chest. Was fit for Command Depot in 5 months. Ill (121). Shell fragment perforating R. back tangentially and removed in France from exit wound. Broncho-pneumonia in France. Admitted 33rd day, with signs of a large haemothorax (confirmed by X-ray). Heart not much displaced. Explored 35th day, but only small amount of blood withdrawn which was sterile. In 2 months breath-sounds still faint at R. base ; air entry not quite normal when discharged to Command Depot in 4^ months. Ill (147). Said to be M. G. bullet wound penetrating R. chest, but X-ray showed several small intrathoracic F. B.'s. Admitted 37th day, with signs of moderate-sized haemothorax. Temperature fell to normal just before admis- sion. Explored 26th day, but very little fluid obtained, containing a few polynuclears. Feeble growth of staphylococci. Physical signs had not quite cleared up in 3 months, but had disappeared a fortnight later. Ill (167). Wounded by several small shrapnel fragments, which were not seen by X-ray, in R. chest. Contra-lateral broncho-pneumonia in France. Explored 32 10th clay, but only small amount of thick fluid and clot containing B. aerogenes capsulatus withdrawn. Admitted 18th day with signs of large B. haemothorax and much displacement of heart. Explored 21st day, but only a little fluid, which did not coagulate and contained no cells or organisms, was obtained. Physical signs had not completely cleared up in 2 months, but were nearly gone in 3 months. Ill (194). Shell fragment penetrating R. chest. Small amounts of blood aspirated on 3rd, llth, and 22nd days in France. Sterile, with no excess of leucocytes. Admitted 30th day, with signs of large haemothorax and displaced heart. Heart not normal in position for 7 weeks. Physical signs still present, with a good deal of falling in of chest in 10 weeks. Ill (289). Shell fragment penetrating R. chest 7-5 cm. deep to anterior surface. Aspirated 10 c.c. on 3rd day, later aspirations without result. Ad- mitted 17th day, with signs of a large haemothorax (confirmed by X-ray). Moderate displacement of heart. Aspirated 21st day, but only of partially coagulable blood obtained. Fluid sterile with few cells. Physical signs still well marked in 2 months. Ill (303). Shell fragment penetrating L. chest. F. B. in abdominal wall, L. loin. 7th day explored, sterile. Admitted 24th day, with signs of a large L. haemothorax (confirmed by X-ray), and displacement of heart. Explored in 3 places 35th day without result. Heart normal in position in 5 weeks, but physical signs still present at extreme L. base in 2| months, though expansion was good, and patient fit for Command Depot. Ill (305). M. G. bullet perforating R. chest, sucking pneumo-haemothorax. 5th day aspirated % 1 with much air : no excess of leucocytes, sterile. 12th day aspirated 1. Admitted 24th day. with signs of a large haemo- thorax and displacement of heart (confirmed by X-ray). Explored 36th day in 3 places, without result. Heart normal in position in 5 weeks. Physical signs cleared up in 3 months. Ill (344). M. G. bullet wound perforating R. chest, extensive friction-sounds at R. base during first week in France. Admitted llth day, with signs of a good-sized haemothorax and displacement of heart (confirmed by X-ray). Aspirated 36th day owing to persistence of physical signs, only |- withdrawn. Fluid contained B. pyocyaneus and streptococci, a few cells. Heart normal in position, but well-marked physical signs in 6 weeks. IX. BACTERIOLOGICAL FINDINGS. (1) Variety of organisms. In 80 cases there are notes of the organisms found on culture from fluid withdrawn. 41 of these were resected and drained. 39 recovered without resection. (a) Resected cases. Streptococci alone were found in 12 cases, on the 4th, 5th, 6th, 8th, 9th, llth, 12th, 13th, 14th, 19th, and 38th day ; streptococci and staphylococci were found in 3 cases, on the 15th, 17th, and 19th day ; streptococci and anaerobes in 1 case on the 6th day ; streptococci and pneumococci in 1 case on the 44th day ; strepto- cocci and B. pyocyaneus in 1 case on the 24th day ; streptococci, staphylococci, and B. aerogenes capsulalus in 1 case on the 4th day. In 3 cases more than one examination was made. In the first streptococci and anaerobes on the 13th and 17th day, but P.M. on the 68th day, streptococci only were recovered. In the second case streptococci, B. aerogenes capsulatus, and B. sporogenes were found on the 4th day, but only the two former on the 26th day. 33 In the third, streptococci alone were found on the 19th day, and in conjunction with staphylococci on the 24th day. Thus streptococci were found alone or with other organisms in 22 cases, in all but 6 during the first 3 weeks. Staphylococci alone were found in 8 cases, on the 2nd, 3rd, 7th, 13th, and 31st day, and in 1 case during the 4th and 6th months. In the remaining case the date is not noted. Staphylococci and anaerobes were found in 1 case on the 14th day, staphylococci and pneumococci in 1 case on the 14th day. Pneumococci were found in 1 case, of which the date is not recorded. Anaerobes were found in 4 oases, on the 2nd, 2nd, 4th, and 13th day. A large Gram-positive stre%)tobacillu,s was found in 1 case on the 8th day. In 1 case B. aerogenes capsulatus was found alone on the 2nd and 3rd day, and on the 4th in conjunction with pneumococci. (6) Non-resected cases. Streptococci alone were found in 4 cases, on the 15th, 21st, 26th, and 60th days' ; streptococci and staphylococci in 5 cases, on the 12th, 19th, 22nd, 22nd, and 26th da}*- ; streptococci and B. pyo- cyaneus in 5 cases on the 19th, 20th, 24th, 28th, and 36th day ; with anaerobes in 1 case on the 13th day ; and with. B. pyocyaneus and B. aerogenes capsulatus in 1 case on the 10th day. Streptococci thus occurred alone or with other organisms in 16 cases, in 9 of these after the first 3 weeks, the latest dates being the 36th and 60th days. Staphylococci were found alone in 11 cases, on the 12th, 12th, 12th, 16th, 20th, 21st, 25th, 28th, 29th, 31st, and 53rd day, with anaerobes in 1 case on the 27th day, and with pneumococci in 1 case on the 22nd day. In 1 case they were found associated with B. pyocyaneus and diphtheroids on the 25th day, and in 1 case with B. pyocyaneus and proteus on the 21st day. Anaerobes were found alone in 5 cases, on the 3rd, 10th, 13th, 16th, and 23rd day. B. pyocyaneus was found alone in 2 cases, on the 13th and 17th day. Staphylococci were thus found alone or in combination in 15 cases, as against 10 instances among the empyemas. B. pyocyaneus occurred in 9 cases, as against one case of empyema, in which it was only found in the fourth week ; anaerobes were about equally frequent in both classes. Strepto- cocci were much less frequent in non-resected cases. (2) Lightly infected cases. In Class II of this series (cases in which an intrathoracic operation or excision of wound had been performed in France), a statement as to the bacteriological findings was recorded in 30, 9 of which were reported as infected (30 per cent.), of these 17 had an intrathoracic operation, with 4 infected cases, and 13 34 excision of wound only with 5 infected cases. The examinations were in all cases subsequent to the operation. In Class III (simple haemothorax cases), bacteriological ex- aminations in France or England were noted in 154 cases, 39 of which were found to be infected (25 per cent.). In 28 cases of both classes, the duration of the fever could be determined, and in 7 others it could not have lasted more than a fortnight. The duration therefore was 14 days or under in 34 per cent., and over 14 days in 63 per cent., averaging in the latter group 29 days, the longest period being 67 days. In one case it was of a recurrent type. Duration of Fever in 39 lightly infected cases. 1. No fever after admission to Centre (9 cases). Ill (75). Admitted 15th day, anaerobes reported from France 6th day. Clotted haemothorax. HI (80). Admitted 18th day, anaerobes reported from France 13th day. Ill (97). Admitted 19th day. Fluid reported sterile 7th day. Clotted haemo- thorax. Staphylococci, B. pyocyaneus and diphtheroids 25th day. Ill (218). Admitted 12th day. Aspirated 29th day, very scanty growth of streptococci and B. pyocyaneus. Ill (228). Admitted 13th day. Aspirated 20th day, staphylococci. Ill (252). Admitted 7th day. Aspirated 19th day, stapbylococci and strep- tococci. Ill (304). Admitted 8th day. 13th day explored, B. pyocyaneus. Ill (344). Admitted llth day. Bronchitis and pleurisy, explored 36th day, streptococci and B, pyocyaneus. Clotted haemothorax. II (91). Admitted 18th day. Diplococcus reported from France 12th day. Clotted haemothorax. 2. Not more than 14 days fever (5 cases). 111(113). 14 days' fever. Two aspirations sterile; 13th day Staphylococcus aureus. III (361). 5 days' fever. Aspirated 2nd day, sterile ; 28th day staphylococci. Ill (367). 5 days' fever. Small haemothorax, explored 10th day ; B. pyo- cyaneus, a few streptococci, and B. aerogenes capsulatus. Ill (418). 6 days' fever. Temperature practically normal after aspiration. Explored 16th day, staphylococci. II (124). 4 days' fever. Aspirated 22nd day, streptococci and staphylococci. 3. Recurrent fever (1 case). III (366\ 6 days' fever. Temperature then normal till 15th day when slight rise began, and subsequently attained 102-4. Aspirated 21st day, scanty growth Streptococcus faecalis. Temperature normal 24th day. 4. More than 14 days' 1 fever (22 cases). Ill (139). 31 days' slightly irregular temperature. Aspirated 18th day ; a few staphylococci, a few B. pyocyaneus, a few B. proteus. Ill (132). 34 days' slightly irregular temperature. Aspirated several times before admission on 20th day. Aspirated 21st day. B. pyocyaneus and a few streptococci (pneumo-haemothorax). Ill (137). 18 days' fever. Explored 27th day, staphylococci and very slight growth of B. aerogenes capsulatus (small clotted haemothorax). Ill (129). 30 days' slightly irregular temperature. Aspirated 22nd day, staphylococci and streptococci, (open pneumo-thorar, plugged at C.C.S.). HI (147). 25 days' irregular fever. Explored 53rd day, feeble growth of staphylococci (pneumo-haemothorax, clotted). 35 III (161). 25 days' irregular fever. Aspirated twice before admission on 28th day. 4th day streptococci and a few anaerobes, 18th day sterile. Ill (167). 21 days' slightly irregular temperature. Explored 9th day. B. aerogenes capsulatus, also signs of contralateral broncho-pneumonia. Explored 51st day. sterile (small clotted haemothorax). Ill (199). Admitted 19th day with slight fever. Aspirated 23rd day. staphy- lococci and pneumococci. Temperature normal 24th day (pneumo-haemo- thorax). Ill (212). 37 days' slightly irregular temperature. Aspirated 24th day, streptococci and B. pyocyaneus. Ill (217). 51 days' fever. Aspirated early in France, explored 31st day. Staphylococcus aureus. Bronchitis. Ill (242). 27 days' fever, which subsided after aspiration. Staphylococci. Ill (253). 16 days 1 fever. Aspirated 18th day, a few B. pyocyaneus. Ill (29bj. 20 days' fever. Aspirated 16th day, staphylococci and B. per- fringens. Lysis beg in after aspiration. Ill (308). 25 days' slightly irregular temperature. Fell to normal after aspiration, staphylococci. Ill (393). 17 days' fever. Aspirated 12th day, streptococci and staphylococci. Temperature rose abruptly after aspiration and fell by lysis. Ill (420). 27 days' slightly irregular temperature. Aspirated 2nd day, sterile. Broncho-pneumonia (contralateral) during 1st week, explored 26th clay, staphylococci and streptococci (clotted haemothorax). II (41;. 45 days' slightly irregular temperature. Aspirated 6th day, B. aerogenes capsulatus, 10th day sterile. Histoiy of Bronchitis before admission on 30th day. II (45). 39 days' fever. Aspirated 2nd day, sterile ; 25th day, staphylococci. II (56). 67 days' fever. Aspirated 9th day in France. Temperature was gradually subsiding, but was not normal till after aspiration 67th day, feeble growth of streptococci. Large pneumo-haemothorax. Laceration of spleen. II (75). 38 days' fever. Aspirated and found sterile several times during first 3 weeks in France. 28th day aspirated, streptococci and B. pyocyaneus (pneumo-haemothorax). II (128). 47 days' fever. Aspirated 2nd day in France. Aspirated 15th day, streptococci (pneumo-haemothorax). II (130). 36 days' fever, wound discharging, much pleurisy, explored 12th day, staphylococci (clotted haemothorax). 5. Cettulitis ( 1 ease). II (82). Prolonged fever due to cellulitis of arm, aspirated 22nd day, strep- tococci. X. CELL COUNTS. Seventy-six cytological examinations of the pleural fluid from 72 patients were reported from France or carried out after admission of the patient to the Centre. In 50 a full differential count was made, in 26 the cells were either absent or too few for accurate counting, or only a partial report was received. The earliest differential count was macle on the 9th day, the latest on the 67th. The counts, however, showed extreme variation ; even when the sterile and lightly infected cases were grouped separately the counts in two cases on the same day after the wound were often quite dissimilar. When the cell counts were grouped in weeks instead of days, and an average for each week taken, a certain broad tendency could be observed, as will be seen in the following Table : 36 TABLE XIII. WEEKLY AVERAGES OF CELL COUNTS. Sterile. C ^? s i 2 8 42 30 28 3 14 24 48 28 4 7 29 46 25 5 5 30 55 15 6 1 15 80 5 10 Infected. S 15 1 K ?* *X * % % 2 3 30 40 30 3 7 26 41 33 4 10 25 37 38 5 Q ; . 10 1 10 10 80 It appears from this Table that in the sterile cases, the poly- nuclear cells, and to a less extent the endothelial cells, tend to decrease, while the mononuclear cells tend to increase. In the infected cases the polynuclear cells tend to increase, while the endothelial and mononuclear cells tend to decrease. The cell counts already tabled in the section on inaspirable haemothorax cases do not differ in type from the general average, if the one somewhat doubtful count is excluded. In the sterile cases, those showing a high mononuclear count appeared to clear up in a shorter time after the date of the aspiration or exploration than those showing a high polynuclear or endothelial count and a low mononuclear count. In 12 cases in which the mononuclear count was 50 per cent, or over, 11 showed a good or fair result in an average of 24 days, and 1 a poor result in 21 days, 6 had cleared up or nearly so within 15 days. Four cases in which the mononuclear count was 20 per cent, or under, cleared up on an average in 56 days. In 7 cases in which the polynuclear count was 50 per cent, or over, 5 cases cleared up or nearly so in an average of 61 days, and 2 showed a poor result in 14 and 75 days. In 7 cases in which the polynuclear count was 50 per cent, or over, 6 gave a good result in an average of 33 days. One was only observed for 5 days more, and had then partly cleared up. In the infected cases the results were discordant, the reaction to the presence of organisms being apparently the determining factor in the cell count. In 7 cases with a high polynuclear count only one cleared up within 3 weeks, and 4 which were aspirated or explored later in the course of the case still showed a poor result in 3 or 4. weeks or longer. In these cases the pro- bability of residual clot or fibrinous pleurisy accounted for the persistence of physical signs. In a few cases an excess of polynuclears was noted during the first week in France, but bacteriologically they were sterile. In the series of counts made at the Centre a polynuclear count of over 50 per cent, occurred in an equal number of sterile and infected cases (8 of each). In 20 cases no cells or only occasional cells were reported ; in 37 13 the fluid was sterile and in 7 infected. Seven (or one-third) were examples of inaspirable haemothorax. The earliest case was explored on the eighth day, and the latest on the fifty-third clay. Only four were found within the first fortnight after the wound. XI. GROCCO'S PARAVERTEBRAL TRIANGLE. In 95 cases of haemothorax the presence or absence of this sign was noted in the reports. In 52 per cent, it was present and in 48 per cent, it was absent. Many of the latter cases were small effusions. It was not noted in any case in which there was demonstrably no fluid. It was, however, no indication of the occurrence or otherwise of partial clotting. XII. COMPLICATIONS. I. Pulmonary and Thoracic. Bronchitis . . . . Pneumonia Same side Contralateral . , , . Broncho-pn eumoni a Same side . . , . Contralateral . . . ... , Pneumonia and subphrenic abscess . Pneumonia and jaundice Pleurisy dry Same side ....-., Contralateral . . x . Both sides ...... With effusion Same side ...... Contralateral . . ; Pericarditis dry . . "With effusion ..... Haemopericardium and pleurisy Pericarditis and pleurisy . , , . Adherent pericardium . Dilated heart . . . - .' . . , Tachycardia (Duration 3 months and 5 weeks.) Mediastinal abscess . . ,, . '< ....... ' Abscess of lung . . t . , Recurrent haemoptysis . . . , (6 months after wound,) II. Abdominal. Biliary fistula . . . ; . .-;..:. -- Serous peritonitis . . . ; ,; . -: Wound of kidney . Bruising of kidney . . . v . . 18 cases 2 11 1 case 3 cases 1 case 1 27 cases 5 2 5 2 4 2 1 case 1 1 ,, 6 cases 2 2 1 case 1 3 cases 1 case 3 cases o 38 III. Nerve legions. Brachial plexus 20 Axillary nerve trunks . ' . . . . 1 case Nerve trunks upper extremity ... 9 cases IV. Vascular lesions. Damage to subclavian artery . . . 3 Damage to arteries in upper extremity . I case Femoral thrombosis 1 Y. Fractures and injury of bones and joints. Humerus . . . ' . . . . .8 cases partial . . . '. . 2 Radius and ulna . . . /, ,< . . 2 Radius ........ 5 TJlna . Vl . . 2 Phalanges of fingers . * . 3 Tibia . . . . . . . .1 case Fibula 1 Jaw 1 Skull ,*j . . 1 Injury to head of humerus . ... ' . .2 cases Damaged shoulder joint 3 VI. Amputations. Arm ',,''. 1 case Thigh . , v : . 1 VII. Miscellaneous. Subcutaneous emphysema . . . . 36 cases Jaundice ...... ( ^..^ . 1 case Retention of urine (first few days) ... 2 cases Multiple arthritis . . . . . .1 caso Multiple wounds . . . .' t . .4 cases XIII. LATE SYMPTOMS. Nearly all cases of gunshot wound of the chest, except those which are non-perforating, suffer from more or less dyspnoea and pain for a variable period. The dyspnoea, which is noted during the earlier stages while there is still fluid or air in the pleura, is generally more marked in the latter condition; but when the physical signs have cleared up, there is often slight dyspnoea on exertion, which may persist for 2 or 3 months, and is gradually relieved by exercises and graduated route marches. In two cases admitted to the Centre who had been wounded in the chest early in the war and returned to duty, the men stated that severe strain or long and arduous marching caused pain and dyspnoea, but it did not seem to have produced serious disability, as they were only sent to hospital when wounded for a second time in the chest. 39 000078136 9 The pain is sometimes fairly severe and constant, and is usually felt along the costal margin, radiating downwards into the abdo- men, or upwards into the thorax. It has never in our experience caused sufficient disability to prevent a return to duty, though it has sometimes persisted for 3 or 4 months. Diaphragmatic adhesions have been observed in the cases examined by X-rays. Both pain and dyspnoea are usually attributed by the patients to the retention of a foreign body, but they certainly occur with equal frequency in cases where no foreign body can be demonstrated. Rather severe dyspnoea has been noticed in a few cases, usually in officers, which persists even on slight exertion for 6 weeks to 2 months. No anatomical cause could be found for this, and it seems probable that it is a neurasthenic condition. It clears up eventually. The presence of large and deeply adherent scars is a true disability, and is especially noted in empyema cases which have been drained through an incision high up in the chest, near the outer scapular border. The cases with a foreign body near the heart, or actually in the pericardium, did not present any special symptoms while under observation, but it was considered more prudent to re- commend them for discharge as unfit. In one case, however, the patient was sent to Command Depot from a convalescent hospital, but his ultimate fate is not yet known. He was probably still in the depot when the armistice was declared. i XIV. TRANSPORT TO ENGLAND. The great majority of the cases bore the journey extremely well, even those evacuated under pressure during the first week or so. The chief complaint was dyspnoea, owing to the length of time they had to lie flat, and this was most marked in pneumothorax cases, and frequently only slight with even large fluid eifusions. We had no direct evidence of increased haemorrhage due to the journey to England, though in a few cases in which there was a moderately large effusion the note made at the casualty clearing station was to the effect that the haemothorax was small. This may have been an error due to necessarily hurried examination, or possibly serous effusion had increased the bulk of the fluid during the week or ten days which elapsed before the patient arrived at the Centre. The cases which bore the journey badly and arrived more or less collapsed were (1) those suffering from severe septic absorp- tion. (2) emaciated cases with bed sores, who had been long in hospital in France, (3) those with other severe injuries. Septic cases, such as empyemas which were draining well and in which the temperature had fallen, felt no ill effects from the journey to England. In no case was the patient's ultimate recovery prejudiced, as far as could be seen, by the transfer to England. In concluding this Repoit, I wish to express my acknowledge- 40 ments for the valuable help I have received from the following Dr. Matthew Young, of the Statistical Department of the Medical Research Committee, who has traced the histories of cases dis- charged from Command Depots ; Professor "Walker Hall, who has conducted the bacteriological and cytological examinations at the Laboratories of the University of Bristol ; the Medical Officers in charge of auxiliary hospitals who have filled in and returned the forms sent them relative to the condition on discharge of their patients, and especially to Dr. Nesbitt Burns, of Hart House, Red Cross Hospital, Burnham; and "W. Groom, Esq.. of the Inquiry Bureau, 2nd Southern General Hospital, who has given valuable assistance in tracing discharged men. The expense of purchasing certain appliances and instruments, and sundry requirements for the proper indexing and reporting of the cases, have been defrayed by a grant from the Medical Research Committee. UN.VERSITY OF CAU LOS ANGELES LIBRARY GOVT. PUBS. ROOM