PLEURAL EFFUSIONS. — The differ ential diagnosis between croupous monia and pleural effusion is sometimes difficult. This is particularly the case in those instances of pleural effusion in which bronchial breathing and bron chophony are decided physical phenom ena. The onset of pleurisy, however, is not characterized by symptoms of the same intensity as attend the onset of croupous pneumonia. The chill is usu ally not severe: more frequently mere chilliness. The fever describes but a moderate curve: rarely above 102° F. There is usually less cough and less abun dant expectoration, and, of course, the rusty sputum is entirely absent. In pleural effusion the physical examination reveals alteration in the contour of the affected side of the chest, partial efface ment of the intercostal spaces, restriction of the respiratory movements upon the affected side, and a possible visible dis placement of the apex-beat of the heart; the vocal fremitus, also, is usually absent, while in croupous pneumonia it is in creased. Percussion in pleural effusion
usually yields a note that is dull or flat; in croupous pneumonia dullness is only partial. Of first importance in the dif ferentiation of these two affections is the position of the adjacent viscera. In left sided pleural effusion displacement of the heart to the right occurs, and depression of the fundus of the stomach results in the obliteration of the so-called semilunar space of Traube. In right-sided pleural effusion the heart is displaced to the left and the liver is displaced in the down ward direction. In pneumonia the ad jacent organs undergo no displacement. On auscultation the breath-sounds and voice-sounds in pleural effusion are usu ally diminished in intensity or possess a very distant bronchial character. In pneumonia bronchophony and bronchial breathing are very marked.