Pleurisy is also met with as the result of accident—fracture of the ribs, with local injury of the serous membrane. This fact is one that ought not to have been passed over in obtaining the history of the case, and it can scarcely be so, because the patient knows of the injury and feels the pain, while he knows nothing of the pleurisy ; he therefore talks of this accident as the cause of his sufferings. It is the business of his medical attendant to find out the pleurisy, remembering that the signs will be a good deal modified by the cause; for the of breathing on the painful side will occur as in pleurisy, because of the aggravation of the pain by breathing; but when the movement of the fractured rib is prevented by the support of a bandage, the breathing is again at once in great measure restored, if pleurisy have not supervened. Spitting of blood may have attended the accident, the lung structure having been torn; and we may find emphysema or pneumothorax, as the result, to complicate the diagnosis.
Pleurodynia is sometimes in all probability only a very limited form of pleurisy, which speedily contracts adhesions, and gives rise to no positive auscultatory phenomena : such we may feel sure is its meaning when it occurs in a case of tubercular disease.
But the name is intercostal to muscular rheumatism affecting the and other respiratory muscles : it occurs as a siidden attack of pain in the side, which interferes with the breathing, catches the patient in attempting to cough or inspire deeply, and may even give rise to the motionless condition of the ribs and want of breath-sound which have been spoken of as accompanying the early stage of pleurisy. The diagnosis rests on the absence of febrile disturbance, the extent over which pain is felt, the existence of superficial tenderness, and the character of the pain, which is rather a diffuse soreness, as if the side had been bruised, than a sharp stitch, like that of pleurisy : the pre sence of rheumatism in any other organ would give great assur ance of its nature, as also the fact of its being excited by any muscular movement, such as raising the arm, or bending the body from side to side.
§ 5. Pnewnothorax.—This seems the most proper place for introducing a few remarks upon this disease, bee,ause it presents some relations to pleurisy. Its history is necessarily one of pre vious ailment: if the patient be known to have had phthisis, we conclude that the air has made its way by ulceration from within outwards ; if he be known to have had pleurisy, we suspect empyema has existed with suppuration and abscess of the lung. It may also occur as the sequel of an accident c,ausing rupture of the lung, or of a natural or artificial opening through the parietes for the exit of pus or serum from the pleura: in such cases the amount of air is commonly less than when an ulcerated opening into the lung exists. In cases of phthisis the event has probably happened with a sensation of something having given way in a fit of coughing or in some unusual strain ; in empyema the first event is the discharge of a large quantity of pus by expectora tion: the latter is, however, a very rare occurrence. In either
case there is excessive dyspno3a ; sometimes with, sometimes without pain on the affected side : and fluid, if not previously present, is very soon secreted.
The febrile symptoms are generally evident enough, but not severe ; and they necessarily present a low type in consequence of the previous condition of the patient. His aspect is generally expressive of anxiety and depression, with more or less dusky discoloration of the h.ce. He very commonly seeks a semi-erect posture, inclining to the side of the disease ; but not unfrequently there is no urgent dyspncea till an attempt at movement be made, when it immediately becomes very marked.
The affected side of the chest is rounded and motionless, has a loud tympanitic resonance, with a wooden hollowness if pleurisy exist ; and then there must also be dulness at the base, in pro portion to the amount of fluid. Throughout the whole of that aide there is entire absence of the vesicular murmur ; at the upper part some of those sounds may be heard which accompany consolidation, when such a condition has prevented the lung from completely collapsing. Amphoric breathing is beard more or lees loudly as we chance to listen near to or at a distance from the opening into the lung, or it may be suspended by temporary closure of the aperture : when present it is accompanied by am phoric voice-sound, which is usually more general. When these signs exist, taken in conjunction with the history, and with the tympanitic resonance, pneumothorax cannot be mistaken for any thing else ; the possible error of mistaking a large cavity for a case of this disease will be discussed along with the evidence of vomic.te in phthisis. If the aperture be closed, the stillness throughout the chest is such as no extreme of emphysema ever simulates : if there be any doubt, we observe that on the affected side there is none of the heaving movement of the upper ribs, and the drawing inward of the lower, so remarkable in extensive emphysema; while on the opposite side there is no prolonged or sonorous expiration; we only discover exaggerated natural breath ing (puerile as it is called), so far as the lung is healthy : and this is most evident about the centre of the chest, where we escape alike from the signs of tubercle and of bronchitis or partial pleurisy on that side. But the history of the case ought to set us free from any doubt between emphysema and pneumothorax; and if the signs of phthisis be met with in the clavicular region, they would only tend to confirm the diagnosis, because tubercular ulceration is one of the causes of the disease : but they are not often present, for, unless the apex be fixed by adhesion, it is certain to be displaced inwards, and adhesion acts as a safeguard against the escape of air into the pleura.