of blood were added: occasional lividity of countenance; severe
dyspnoea, accompanied by inability to lie on the sound side or to
assume the supine position; absence of respiratory movement on the
injured side; pain, restlessness, cough, and sometimes continuance of
haemoptysis, small clots usually being expectorated.

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

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

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

The most interesting feature was offered by the temperature, as this was
very liable to lead one astray. A primary rise always occurred with the
collection of blood in the pleura, this reaching its height on the third
or fourth day, usually about 102 deg. F. in well-marked cases; it then fell,
and in favourable instances remained normal. In a large number of cases,
however, where the amount of blood was considerable, this was not the
case, the primary fall not reaching the normal, and a second rise
occurred which reached the same height as before or higher. The second
rise was accompanied by sweating, quickened pulse, and the probability
of the development of an empyema had always to be considered. I believe
in most cases this secondary rise was an indication of a further
increase in the haemorrhage, for the dulness usually increased