Another occasional consequence of long-standing pleurisy is a fibroid change at the base of the lung leading to induration of the tissues and di latation of bronchi: This subject is elsewhere referred to (see Fibroid In duration).
Varieties. —Certain varieties of the disease are commonly met with. In some cases the lymph exudation is unaccompanied by liquid effusion (plas tic or dry pleurisy). In others, the inflammation, instead of being general over the whole side, is confined within certain limits (localised or loculated pleurisy). In others, again, the disease may attack the two sides simulta neously. Double pleurisy is often in the child the consequence of tuber culosis.
Plastic Pleurisy, although sometimes primary, is for the most part in young subjects secondary to some other disease. It is common in cases of phthisis, and sometimes occurs in the course of catarrhal pneumonia. Dry or plastic pleurisy is often overlooked, as it may give rise to but few symp toms, or to symptoms so slight that they are masked by the other more prominent manifestations of the disease in the course of which they have arisen. This form is of little importance. It is usually accompanied by some pain in the side and a teasing cough. On examination of the chest, dulness is discovered at the seat of pain, and a little crepitating friction or a superficial rub can be heard with the stethoscope. The inflammation leads to adhesion between the opposed surfaces of the Loculated Pleurisy is very common in children. The inflammation may occupy any part of the serous surface. It may be limited to the membrane covering the diaphragm or to that surrounding the base of the lung ; it may be seated at the upper part of the pleural cavity, such as the infra-clavicu lar region ; or it may occupy the space between the lobes. In many cases the localisation of the disease is due to old adhesions resulting from a pre vious attack, so that the fluid thrown out is prevented from gravitating downwards or spreading over the general cavity of the pleura ; but in others no history of a similar illness can be discovered.
In ordinary cases of loculated pleurisy the general symptoms do not differ from those met with in the more common form of the disease. But the physical signs are more characteristic. Over the collection of fluid the percussion-note is completely dull, with great sense of resistance ; the res piration is weak, and may be of bronchial, blowing, or cavernous quality ; there is seldom any friction-sound to be heard, and the vocal resonance is ordinarily suppressed. Such signs may be discovered over the whole front
of the chest ; they may be limited to the infra-clavicular or infra-mammary regions ; they may be found in the scapular region behind, or at the lower part of the axillary region at the side. The most difficult to detect of these partial pleurisies is no doubt that variety in which the inflammation and effusion are confined to an interlobar space. In such a case there may be considerable retraction of the side from compression of the lung ; or the physical signs may occupy so limited an area as to escape recognition, and there may be no displacement of the heart. After the fluid has become purulent, the cough, the wasting, and the cachectic appearance of the child, coupled with the insignificant character of the physical signs, often suggest tuberculosis.
Diaphragmatic pleurisy is rare in the child. The disease begins sud denly with a severe pain shooting across the chest and great oppression of breathing. The child sits up in bed with a distressed face. His skin is hot, and every attempt to draw a deep breath is a cause of great suffering. The physical signs are often very indefinite ; but usually some dulness may be discovered at the extreme base on one side, with weak breathing ; and often after a day or two the ordinary signs of pleurisy can be detected at the lower part of the same side ; for diaphragmatic pleurisy rarely re mains limited to the diaphragm in early life.
Tuberculous Pleurisy. pleurisy occurs as a consequence of tuberculosis it is usually double ; but every case of double pleurisy in child is not necessarily tuberculous. Nor, again, in every case of pleurisy in a tuberculous subject is the serous inflammation always seeon dary 'to the diathetic disease. It has been already stated that tuberculosis is a common sequel of empyema of long standing ; and a purulent collec tion in the chest precedes tuberculosis much more often than it follows it. In cases where pleurisy is met with as a secondary disease the inflamma tion is usually of the plastic variety ; although sometimes there is also serous or purulent effusion in the chest-cavity. We can only say positively that tuberculosis is the primary disease when the symptoms of the con stitutional malady—wasting, moderate fever, loss of colour and strength, a distressed expression of face and occasional cough—have preceded by a definite interval the local signs of serous inflammation.