As to the cases of hæmothorax and empyema which needed drainage, all did well; but expansion of the lung was much less satisfactory than would have been expected, probably on account of especially firm adhesions. The importance of concurrent injury I need hardly dwell on; but I might add that perforation of one or both arms, the most common one, did not materially affect the general statements above made.
Treatment.—In the early stages of the pulmonary wounds rest was the all-important indication, and when this was assured few serious cases of hæmothorax occurred. Beyond simple rest, the administration of opium with a view to checking internal hæmorrhage was used with good effect. The wounds needed simple dressing only.
The treatment of hæmothorax at a later date, however, was of much interest and difficulty. I think the following lines may be laid down for guidance in such cases:—
(i) Hæmothorax, even of considerable severity, will undergo spontaneous cure. An early rise of temperature may be disregarded.
(ii) Tapping the chest is indicated when pressure signs on the lung are sufficiently severe to cause serious symptoms, and the removal of the blood undoubtedly shortens the period of recovery, as well as relieves symptoms.
In such cases the collection of blood has usually been rapid and continuous; hence a fresh hæmorrhage is always probable when the local pressure has been removed. Tapping therefore should not necessarily mean complete evacuation, and should be followed by careful firm binding up of the chest, the administration of opium, and the most stringent precautions for rest.
(iii) Tapping may be needed as a diagnostic aid, and in such circumstances as much fluid as can be removed should be evacuated with the same precautions as mentioned in the last paragraph.
(iv) Tapping may be indicated for the evacuation of serum expressed from the blood-clot, or due to pleural effusion, on the same lines as in any other collection of fluid in the pleural cavity.
(v) Early free incision is, as a rule, to be steadfastly avoided. Some cases already quoted fully illustrate its disadvantages.
(vi) Cases in which an incision and the ligature of a parietal artery are indicated are very rare. I never saw such a one myself.