In acute cases, the beginning of the disease often manifests itself by symptoms appearing in rapid succession. The patient is attacked in the best of health by malaise, chilliness, fever, and headache. Vomiting frequently occurs, though not as often as in croupous pneumonia. In some cases during the first years of life convulsions and somnolence occur, whenever the disease is ushered in with a high temperature. From the beginning, respiration is painful, increased, suppressed, and super ficial. Older children complain of a very painful spot in the side; y-ounger children refer the pain to the epigastric region. The pain may be much more severe than in pneumonia. A painful, dry, short, and very harassing cough often sets in, but may also be absent. Examination often reveals on the first or second day the presence of a fibrinous pleurisy by friction sounds, diminished breathing, and local pain on pressure over some point of the pulmonary surface. Cases of acute fibrinous pleurisy of this kind often recover in a short time, uith a rapid abatement of the fever and other symptoms. They do not present anything special, and will therefore not be considered any further.
Whenever a pleuritic effusion has taken place the clinical picture is different. This condition is often demonstrable as early as the second or third day', usually', however, only' later. The following synaptotns then develop according to the size of the effusion and the rapidity with which it accumulates. The child avoids unnecessary 'motion and prefers to he on the affeeted side in order to use the souni lung for breathing. For this reason, nurslings often will only- clrink from one breast, for instance, in right-sided effusions from the left breast. The expression of the face is anxious, and painfully distorted in coughing or crying. The lips and cheeks are pale. The breathing is still rapid and superficial, hut expiration is often not as suppressed and grunting because the pain usually, subsides with the appearance of the effusion. The sound side breathes more deeply than the affected one. llyspncea makes it.self mani fest while speaking or making any movement, and increases with the amount of the effusion, and may be accompanied with cyanosis i» case of considerable displacement of the heart. Inspiratory' recessions of the lower aperture of the thorax are less common than in pneumonia. in large effusions they are more apt to affect the sound side. The cough frequently disappears while the effusion is taking place, but may also continue and be spasmodic in character. It is frequently followed by suppressed crying or whining. The patients avoid loud crying. Many
times they do not seem to suffer any pain, so that in the absence of cough there is nothing to direct the attention to the chest, leaving the general indisposition to control the clinical picture—fever to a more or less degree, malaise, coated tongue, poor appetite, disturbed sleep, restlessness, increased pallor. The amount of urine is diminished, especially' in rapidly increasing effusions, alburninuria sometimes occur ring if the temperature is high. Often there is constipation. Under these circumstances, only- a careful and systematic examination will guard against overlooking a "latent pleurisy'," or perhaps even the assumption of "dentition fever." In effusions of an appreciable degree the physical examination reveals very important signs. Inspection shows an obviously diminished excursion and dragging of the affected side, besides the accelerated, superficial, ancl, when pain is present, jerky respiration. In very exten sive effusions severe dyspiwca and expiratory distention of the veins of the neck are seen. The affected side may be almost motionless. Oblitera tion of the intercostal spaces is rare in acute cases, and may even be absent in purulent cases, contrary to a widely accepted opinion. On the other hand, one can readily recognize with the unaided eye, dis tention of the affected half of the chest, in extensive effusion. This is especially plain in front below the clavicle, and when the patient is observed from behind while in a sitting posture. Often there is also elevation of the shoulder. This distention of from 2-4 cm. ntay be easily established with the tape measure. The frequent use of the tape measure is to be recommended, because the increase and decrease of the effusion may thus be de termined. Even after the disap pearance of the fever, the accel erated • superficial breathing is still conspicuous. A diminution in the size of the affected side of the chest, with descent of the shoulder and stancling off of the scapula, is often found after absorption of the effusion.
Palpation commonly reveals sensibility to pressure, especially if it is made between the inter costal spaces even in children who otherwise do not complain. This is in favor of pleurisy in so far as there is no active rachitis of the ribs. In large effusions a displacement of the apex beat and descent of the lower hepatic border are often to be felt.
Percussion is the most important part of the exatnination plettrisy with effusion. It permits of a much more certain judgment than auscul tation, and is best c•arried out with the patient in an upright position.