PHYSICAL SIGNS.—These depend chiefly on the nature and amount of the exudation. (a) In pleurisy with recent fibrinous exudation on inspection the movements of the affected side are seen to be restrained on account of the pain; the expansion may be jerky. The patient often lies with the body bent toward the affected side. On palpation vocal fremi tus is usually unaffected unless the exu dation is abundant, when it is lost. Oc casionally friction-fremitus can be felt.
Percussion may yield negative results, or there may be somewhat diminished resonance, owing to lessened expansion of the lung and the considerable amount of plastic exudation.
For the same reasons, on auscultation the breath-sounds are weak or even ab sent. Friction-rub may be heard and is the diagnostic sign. When well defined it is heard as a to-and-fro sound in in spiration and expiration. It may be heard in deep inspiration only. Usually in children and not rarely in adults it is absent. It may be heard only in small areas,—in the inframammary or axillary is therefore liable to be overlooked. It is formed by a succession of superficial creaking or rubbing sounds, but may resemble a crackling rale. It lasts but a few hours in cases of rapid effusion. In pleurisy in the neighbor hood of the heart a friction-sound of car diac rhythm may simulate pericardial friction.
(b) In pleurisy with effusion inspection also furnishes valuable assistance. If with the occurrence of effusion separat ing the pleural surfaces the pain is relieved, the chest-movements become more free. However, as the fluid in creases the expansion lessens and disap pears if the effusion becomes large, while that of the unaffected side increases. The intercostal depressions become widened and obliterated, giving the chest a smooth, rounded appearance with in crease of the antero-posterior diameter. In large effusions the mediastinum is dis placed toward the sound side, most mark edly so in effusions into the left pleura. The position of the cardiac impulse is the best index to the degree of medi astinal displacement, and therefore of the amount of pleural effusion. It may appear at the left axillary line or as far to the right as the right mammary line. The downward displacement of the dia phragm is measured by the position of the liver and spleen, the lower borders of which may be at or below the um bilical line.
In acute inflammation of the pleura we not infrequently have abdominal pain. This is sought to be accounted for in various ways. One is that the lower six intercostal nerves supply not only the pleura, but also the abdominal muscles; hence the pain could be readily referred to the abdomen. Again, the phrenie nerve may play some part in this peculiar condition. This referred pain may give rise to the diagnosis of appendicitis, cholecystitis, etc., when the real lesion is a pleurisy or a pnemnonia. The writer gave the histories of several cases in which a mistake in diagnosis had been made in some in which ap pendicectomy had been done under a wrong apprehension. In children it ap pears not necessary that the lower lobes of the lung be affected to cause this re ferred pain, as it may occur when the pneumonia is apical. J. B. Herrick (Amer. Medicine, May 16. 1903).
The important sign of liquid effusion on percussion is the flat note and the in creased, or "board-like," resistance over the whole surface of effusion. This loss of resonance and elasticity is due chiefly to the liquid in the pleural cavity, but partly also to the collapsed state of the lung beneath the fluid. The dullness extends from the base upward, usually highest in the axilla and sloping some what lower to the front and back. When the effusion rises higher than the angle of the scapula the lung will have relaxed to such a degree as to give a tympa nitic note above the nipple: the Skoctaic resonance. Posteriorly the note is usu ally somewhat impaired far up the back. The level of the fluid is usually altered by a change of position of the patient. On this point, however, different observ ers report different results. Possibly in moderate effusions the fluid changes gradually with change of position of the patient if there are no adhesions. In some cases, in which the effusion has formed in the recumbent position, the area of flatness corresponds with the sur face of the lower lobe of the lung; but in some of these the exudate is almost wholly fibrinous. The lower limit of flatness on the right side passes into and cannot be distinguished from liver-dull ness; on the left extends to and, in large effusions, it obliterates stomach-reso nance: Traube's semilunar space.