. Physical diagnosis . t of effused air increases, and closed pneumothorax is one inwhich the physical signs remain stationary.) Differential Diagnosis. The distinction between pneumothorax and emphysema has al-ready been discussed. (a) When the air in the pleural sac is under such tension thatthe percussion note is dull, the physical signs may simulate pleu-ritic effusion, but real flatness, such as characterizes effusion, hasnot, so far as I know, been recorded in pneumothorax, and thesense of resistance on percussing is much greater over fluid thanover air. In case of doubt puncture is deci
. Physical diagnosis . t of effused air increases, and closed pneumothorax is one inwhich the physical signs remain stationary.) Differential Diagnosis. The distinction between pneumothorax and emphysema has al-ready been discussed. (a) When the air in the pleural sac is under such tension thatthe percussion note is dull, the physical signs may simulate pleu-ritic effusion, but real flatness, such as characterizes effusion, hasnot, so far as I know, been recorded in pneumothorax, and thesense of resistance on percussing is much greater over fluid thanover air. In case of doubt puncture is decisive. DISEASES AFFECTING THE PLEURAL CAVITY 335 (b) Acute pneumothorax, coming on as it does with symptomsof collapse and great shock, may be mistaken for angina pectoris,cardiac failure, embolism of the pulmonary artery, or acute pulmo-nary tympanites (see above, p. 315). From all these it can be distinguished by the presence of am-phoric or metallic sounds, which are never to be obtained in theother affections FIG. 169.—Diaphragmatic Hernia. The outline of the displaced diaphragm visible below theleft clavicle. Heart displaced to right of sternum. (From v. Ziemssens Atlas.) (c) Hernia of the intestine through the diaphragm (see Fig. 169)or great weakening of the diaphragmatic muscular fibres, may allowthe intestines to encroach upon the thoracic cavity and simulatepneumothorax very closely. The history and course of the case, theabdominal pain, vomiting, and indicanuria, generally suffice to dis-tinguish the condition. The peristalsis of the intestine may go oneven in the thorax, and gurgling metallic sounds corresponding to itand unlike anything produced in the thorax itself may be audible. 336 PHYSICAL DIAGNOSIS. The distinction between open and closed pneumothorax, to whichI have already alluded, is far less important than the presence orabsence of (a) Pulmonary tuberculosis (b) Encapsulating adhesions in which the air is confined to acircumscribed area (a) The e
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