Acute idiopathic inflammation of the pleura usually commences by rigors, preceded perhaps by some signs of general uneasiness, which soon become those of great febrile excitement. Pain is early felt in the side in the course of the sixth, seventh, and eighth ribs, or at the point corresponding generally to the seat of the inflammation. It is usually sharp and darting, is called a stitch, occupies rather a small space, (the point de côté of the French,) and is always increased by drawing a full breath or by coughing. The breathing is short, from the disinclination to fill the chest, by which the pain would be increased; it is hurried, and sometimes takes place as if by jerks, from the necessity for its repetition, in consequence of the smallness of the quantity of air admitted at each attempt. When the attack is very severe the patient tries to breathe with the healthy side only, the lower ribs of the affected side being moved but slightly, and with evident caution. If the inflammation have been caused by extreme violence, pain will also be felt, particularly at the part injured.
When inflammation has affected the pleura covering the diaphragm, especially when caused by external violence, the pain will be felt lower down, so as to lead to the suspicion that it is also abdominal. When jaundice supervenes, it occurs from the extension of disease through the substance of the diaphragm, as is occasionally seen in wounds implicating the chest, the diaphragm, and the liver.
A cough is not a constant accompaniment of the first stage of disease; when present, it is usually dry, slight, infrequent, and does not attract attention, unless accompanied by a thin, frothy mucous expectoration, indicating the presence of bronchitis; of pneumonia, if reddish. The patient usually lies on his back while the pain is severe, and has a great indisposition to turn fully on to the affected side. At a later period, when effusion has taken place, the pain usually subsides, and he turns on the side affected to relieve the difficulty of breathing, caused by the pressure of the fluid on the sound lung through the bulging of the mediastinum; but the manner of lying, or decubitus, is of little importance, and should be subservient to the feelings of the patient, who is sometimes comfortable only when raised to nearly an erect position.
When the complaint is not subdued at an early period, an effusion of serous fluid, more or less in quantity, takes place. The whole cavity of the side affected has been known to be filled in from twenty-four to forty-eight hours, giving rise to symptoms dependent on the degree to which the effusion has taken place; this is the evil which in injuries penetrating the cavity of the chest is most to be feared. When the external wound has been closed, or is so partially closed as not to allow the escape of the effused fluid, it is commonly the immediate cause of the death of the patient. Its secretion and early evacuation are therefore the most important points to be attended to in wounds of the chest.
The respiratory murmur becomes less distinct as soon as the pain prevents the ordinary distention of the affected side of the chest, and diminishes the quantity of air which usually penetrates the lung in any given time. As soon as a thin layer of fluid commences to be thrown out between the pleuræ, this murmur becomes fainter, and when it is complete, it ceases. If the patient can bear percussion, the side affected yields a dull, dead sound instead of the ordinary clear, sonorous one of health. The position of the patient when erect, by causing the fluid to descend, may allow of the respiratory murmur being heard at the upper part of the chest; and it may be perceived in front, but not behind, when he lies on his back, until the cavity is filled, when the sound altogether ceases. At the spot in the back corresponding to the root of the lung, or at any other point at which a previously formed adhesion may retain the lung against the wall of the chest, some respiratory murmur may yet be distinguished, until this part of the lung shall also have yielded to the general compression, so as to be temporarily impervious, or have become solidified under the continuance and extension of disease. While this is taking place in the affected side, the other lung is called upon to make up the work of aerification of the blood; it labors harder, its functions become more energetic, and that side of the chest is more distended; the respirations become quicker, fuller, and louder, and the vesicular murmur is said to resemble that of a child—in fact, to be puerile.
When the lung begins to be compressed by the circumambient fluid and the respiratory murmur ceases, a peculiar modification of the respiration through the large bronchial tubes may be heard, constituting bronchial respiration. It occurs in pneumonia, in pulmonary apoplexy, and in tubercular disease when the lung is solidified. When the voice is heard through the stethoscope in these complaints, the peculiar sound emitted is called bronchophony.
In pleuritic effusion, the voice, when carefully examined, sometimes obtains a character not previously noticed, but of comparatively little importance, called œgophony, a sound which may be easily confounded with bronchophony, of the latter of which it is a modification more often alluded to than observed. Laennec says: “Simple œgophony consists in a peculiar resonance of the voice, which accompanies or follows the articulation of words. It appears to be sharper than natural, more acute and somewhat silvery, vibrating, as it were, on the surface of the lung more as an echo of the voice than as the voice itself. It rarely enters the tube of the stethoscope, less frequently traverses it completely. It has besides another peculiar character, which is constant, and from which I have taken its name. It is a trembling, bleating, or shaking sound, like that of a goat, the tone of which animal it greatly resembles. When it occurs near a large bronchial tube, as in the root of the lungs, a more or less marked bronchophony is often superadded.” This sound may pervade the whole side; it is usually, however, most distinct near the inferior angle of the scapula, the patient being erect. It only exists where the effused fluid is small in quantity, and is never a dangerous symptom; its return, after it has been present and has disappeared, is a sign that a part of the effused fluid has been removed. It is a sign principally of value in distinguishing between pleuritis and pleuro-pneumonia and pure pneumonia, in which latter disease it is not heard, as in that complaint fluid is not thrown out into the cavity of the pleura.
301. In pneumonia or inflammation of the substance of the lung, as distinct from any implication of the pleura, which, however, most frequently obtains after blows on, and in cases of penetrating wounds of, the chest, the symptoms differ. The ordinary febrile symptoms are similar to those of pleurisy, only more intense; they usually precede for a day or two the local symptoms of difficult respiration, pain, and cough. The dyspnœa varies in different people. In some it is only a slight embarrassment of breathing, admitting of partial removal by accelerating the number of the respirations, which are augmented from twenty to thirty, forty, and upwards, and in children to sixty and seventy, marking a great degree of distress and of extent of inflammation, from which, when they are so frequent, persons rarely recover. The patient can scarcely speak or lie down, and is obliged to be supported in that which he finds to be the least uneasy position. Pain is not always present; it is even said to be more frequently absent when the substance of the lung is affected, and not the pleura. That pain is not a necessary concomitant of pneumonia, is admitted, but that it is usually present, and with great intensity in many cases, cannot be doubted. When present, it is usually an early symptom, deep seated below the sternum, under the breast, extending to the scapula. When in the sides it is more acute and fixed, and is probably conjoined with the pain of pleurisy.
The pulse is quick and sharp, occasionally full and hard, at the commencement of this complaint in young and healthy persons, although it is sometimes small and weak from the beginning, where there is little general power; but this rarely occurs in cases of injury, and is not to be relied upon in opposition to other symptoms.
The cough is usually dry in the commencement of idiopathic pneumonia, rarely recurring by paroxysms, and is without any particular indication; it is soon, however, accompanied with a slight mucous expectoration, which, after some twenty-four or forty-eight hours, begins to assume certain and peculiar characters of the utmost importance as indicating the existence and the different stages of the disease. On the second or third day the expectoration becomes bloody. Each sputum, spit, or crachat of the French is composed of mucus intimately combined with blood—that is, not simple streaks or striæ of blood, as in catarrh; nor is it pure blood, as in hemoptysis. Each sputum is either of a yellow, or rusty, or even red color, according to the quantity of blood intimately mixed with the mucus. These sputa are at the same time tenacious and viscous, adhering so intimately together as to form a homogeneous transparent whole, readily gliding, however, from the basin in which they are held on sufficient inclination being given to it. At this period or stage of the disease, the sputa adhere strongly to each other, but the mass is not sufficiently viscid to stick to the sides of the vessel. When no further change takes place in the sputa the inflammation rarely passes beyond the first stage of obstruction or engorgement, or swelling. When they attain to a more viscous state, and adhere to the inside of the vessel in which they have been received, the progress of the inflammation to the second stage, or that of hepatization, may be feared. In almost every case where the viscidity of the expectorated matter increases, respiration becomes dull or bronchial, percussion of the chest yields a duller sound than before, and the inflammation has attained its highest degree. The expectoration, after being some time stationary, changes its character. If the complaint is to terminate by resolution, or by death, or to pass into a chronic state, the redness and viscidity gradually diminish, and at last disappear. If the rust color and the viscidity should return, there has been a relapse, which the reappearance of the other symptoms will show. When the inflammation is of the most serious nature, and about to terminate fatally, the expectoration diminishes, and at last ceases. In some cases it only diminishes because it cannot be discharged; it accumulates in the trachea, in the larynx, and in the bronchi, until the patient is destroyed. In some rare cases the matter secreted is spit up nearly to the last, and in others, still more rare, the approach of death in the last stage is characterized by a brown expectoration which cannot be mistaken for either of the others which preceded it. If the pneumonia pass into the chronic state, the expectoration becomes yellowish, or somewhat greenish, and at last is purely catarrhal.