ALEXANDER MCPREDRAN, Toronto.
PLEURISY.—Inflammation of the pleura may occur as a primary affection, or, perhaps more frequently, it is sec ondary to a general or local disease. Acute Pleurisy.
Symptoms.—In many cases of acute pleurisy the onset is insidious; it is usu ally so when it occurs secondarily to some grace disease whose symptoms mask those of the pleurisy. It is usually latent also when it occurs late in such exhaust ing diseases as carcinoma, nephritis, and tuberculosis.
Ordinarily, however, an attack of pleu risy sets in with slight shivering followed by fever and pain in the side. In some cases there is an abrupt chill, especially in pneumococcal pleurisy, which may closely simulate pneumonia. In children the chill is usually replaced by vomiting, sometimes by a convulsion.
Pain is the most distressing and con stant symptom; it usually occurs in the neighborhood of the nipple or in the axillary region. It may, however, be re ferred to the back or to any part of the abdomen. So severe and circumscribed has it been in the abdomen that a diag nosis of appendicitis has been made and an operation performed. The pain ordi narily is sharp and excruciating, aggra vated by respiratory movements and cough. It is usually relieved when the effusion becomes sufficient to separate the pleural surfaces, but in severe cases it may persist and be felt in the distribu tion of the intercostal nerves in the ab domen. There is tenderness along their course and there seems no doubt that the pain is due to extension of the inflamma tion to the perineural sheaths, possibly to the intercostal muscles in some cases.
Cough is an early symptom, being worse usually in the early stage. It is short, dry, and, as it increases the pain, is repressed as much as possible. There may be slight mucoid expectoration on account of associated bronchitis. The temperature for the first week or ten days usually rises to 101° or 102° F.; in the pneumonic type it may be as high as in pneumonia, with an incomplete crisis followed by a second rise. It generally, however, declines by lysis in about ten days, but the fever may persist for weeks, taking on a hectic character even in sero fibrinous cases, suggestive of suppura tive exudation. Such cases are probably. tuberculous.
The pulse is moderately quickened. The pulse-respiration ratio does not un dergo the marked change so character istic of pneumonia. The respiration is increased in frequency at the outset on account of the pain and later on account of the bulk of the exudate. The effect of the effusion on the respiration depends much on the rapidity of its accumula tion,—a rapid exudation causing much dyspncea, while one slowly formed may produce no conscious disturbance so long as the patient is quiet, although the pleu ral cavity may be moderately distended. In the early stage the decubitus varies, but when the effusion becomes copious the patient usually lies on the affected side.