On inspection of the chest-wall we can often detect a certain impairment of movement on the affected side ; but the intercostal spaces are net necessarily bulged and motionless even in cases where the amount of fluid is large. In young children, whose respiration is principally diaphragmatic, the walls of the chest move comparatively little in inspiration ; and the closest inspection can often discover no difference in this respect between the two sides. Although the intercostal spaces may move as in health, the whole of the affected side is fuller than the It may not, indeed, as has been pointed out by Dr. Gee, show any difference to the measuring tape ; but the outline, as taken with the cyrtometer, is much squarer than natural from a bulging at the antero-lateral angle of the chest-wall. If the amount of effusion is more than moderate, the neighbouring organs are displaced by pressure of the fluid. The liver and spleen can be felt more distinctly than in the normal state, and the heart's apex is pushed to one side. In cases of right-sided pleurisy the apex is displaced to the left, and can be felt beating outside the nipple line. If the effusion occupy the left side, the cardiac impulse may be felt near the ensiform cartilage. These signs, especially the latter, according to my experience, are as well marked in the child as in the adult, and should be always looked for. Displace ment of the heart to the right is sometimes prevented by adhesions formed between the pericardium and the left pleura. Sometimes an alteration in the size of the heart may prevent the displacement of the organ from being noticed. Thus, if the left ventricle is much hypertrophied, the apex-beat -under ordinary circumstances is felt to the left of the nipple line. In such a case displacement of the heart to the right by fluid in the left pleura may do no more than restore the apex-beat to the normal position. A little girl, aged nine years, with old-standing heart disease and hypertrophy of the left ventricle, was admitted into the hospital with considerable pleuritic effusion of the left side. The heart's apex was felt beating behind the sixth rib in the left nipple line. After absorption of the fluid the cardiac apex had moved one inch to the outer side of the nipple line.
Palpation of the affected side does not always discover obliteration of the intercostal depressions, although sometimes it will do so. Often, es pecially in cases where there is little thickness of lymph lining the pleura, a tap with the finger between two of the ribs will be readily transmitted through the fluid to a second finger resting upon a distant part of the same interspace. Vocal vibration of the chest-wall is, as a rule, completely absent in the healthy child. Sometimes, however, if strong on the sound side, it may be conducted by the chest-wall to the other half of the chest, and be felt distinctly over the whole of the affected side. I have known this phenomenon to be present in a case where ten ounces of fluid were removed by paracentesis. Immediately before the operation the vocal vibration was little less strong than on the sound side. On account of its frequent absence, and uncertain value when present, vocal fremitus is not to be depended upon in the young subject. If, however, we can feel a
distinct fremitus over the sound lung, its absence over the affected side of the chest is important ; but this is exceptional.
On percussion of the affected side there is complete dulness with greatly increased sense of resistance. These are very important signs. In no form of pulmonary consolidation—except, perhaps, in extensive fibroid induration of the lung with secondary pneumonia—is such a dull, flat note, with so marked a sense of resistance to the finger, to be found. The impression to the ear and the touch is exactly that derived from percussing a thick block of wood. The dead, flat note is not, however, to be obtained all over the affected side of the chest. In the upper intercostal spaces in front, and along the side of the spine behind, a tubular (tympanitic) note is often elicited, due to the presence of under-lying relaxed lung-tissue ; and in the infra-axillary region it is common to find a well-marked resonance, owing to the transmission of the stomach note through the lower part of the fluid. This pseudo-resonance is often a source of perplexity ; but we usually find that on employing very gentle percussion in this region the note is dull, while a sharper stroke in the same spot produces a loud resonance such as was heard at first. It is very important not to be misled by this source of confusion, for one of the distinctive marks of fluid in the pleura lies in the general distribution of the dull percussion note on the affected side. In ordinary cases of pleurisy the dulness extends all round the side of the chest, both behind and in front, although the upper limit of the dulness rises to a higher level at the back than it does anteriorly.
Besides the general distribution of the dulness, the alteration of the percussion note on change of position is a valuable sign of fluid in the chest.
If the amount of fluid is moderate, and is not confined within narrow limits by adhesions, it tends to gravitate to the most depending part, so that the side of the chest which is turned uppermost gives a clear note to the per cussing finger. This sign is almost invariably present during the stage of absorption.
The auscultatory signs of pleurisy in the child are often very peculiar. Sometimes, as in the adult, we find weak, almost suppressed, breathing over the area of dulness, with an occasional graze or scrape of friction above the upper border of the effusion. Often, however, the signs are much less characteristic. It is not uncommon to find a loud blowing, tubular, or even cavernous breath-sound over the scapula behind and in the axillary region. Sometimes this is heard almost as far as the base, and usually it can be de tected below the level of the effused fluid. This character of the respira tory sound is not confined to cases where the lung is consolidated from pneumonia, for it is often present when the temperature is normal. The vocal resonance may be exaggerated, and about the lower angle of the scapula is frequently bronchophonic. Often it •has a pronounced tigo phonic quality. The bronchophonic character is not, however, always found in places where the breathing is bronchial or blowing. Over a spot where the respiration is typically tubular, vocal resonance may be com pletely suppressed.