PLEURISY. 85 



and in all probability, protrusion of the intercostal spaces will be 

 found to exist. But when the effusion is not very extensive, nor on 

 the increase, it may coincide with a constitutional state but little re- 

 moved from health. 



The cough never occurs in fits ; it is small, as if cut short, and 

 frequent. It may be even entirely wanting, though the inflammation 

 is intense and a considerable effusion exists in the pleura. In pure 

 pleurisy there is little or no expectoration ; but if it be complicated 

 with pneumonia, there will be the characteristic sputa of that affec- 

 tion. 



When the pleura covering the diaphragm is inflamed, the distinc- 

 tive symptoms are said to be, — 1st, a more or less acute pain along 

 the cartilaginous edge of the false ribs, generally extending into the 

 hypochondria, and sometimes even to the flank ; 2dly, complete im- 

 mobility of the diaphragm in inspiration ; 3dly, a very remarkable 

 anxiety, expressed particularly by the sudden alteration of the fea- 

 tures ; 4thly, an almost constant orthopnoea, with inclination of the 

 trunk forwards. Patients in this situation dread the slightest motion, 

 as being calculated to awaken the most violent pain ; this symptom, 

 which is sometimes absent, is considered by M. Andral to be one of 

 the most characteristic. The less constant symptoms are, — hiccup, 

 nausea, and vomiting ; convulsive movements of the muscles of the 

 face, and particularly of those of the lips; delirium, which supervenes 

 either in a continued or intermittent form. Finally, when the dia- 

 phragmatic pleura of the right side is the seat of inflammation, the 

 liver may be sympathetically irritated, and jaundice develope itself. 

 The coexistence of this jaundice with a more or less acute pain in 

 the right hypochondrium may induce one to believe in the presence 

 oi hepatitis. 



Physical signs, — The earliest sign of pleurisy, occurring during 

 the first stage, when the membrane is slightly roughened by lymph, 

 is a rubbing sound heard during the movements of inspiration, and 

 arising naturally from the friction of the roughened surfaces against 

 each other. This sound is often perceptible to the patient himself. 

 But it ceases as soon as the opposing costal and pulmonary mem- 

 branes are separated by liquid effusion. 



When effusion has occurred, it is denoted by dulness on percus- 

 sion of the portion of the chest corresponding to the effusion. ' This 

 dulness, supervening much more rapidly than in ordinary pneumonia, 

 and unaccompanied or preceded by crepitation, generally points out 

 pleuritic effusion. The resonance of the chest is commonly dimi- 

 nished first in the inferior dorsal and lateral regions, corresponding 

 to the base of the lung. As the effusion increases, the dulness of 

 sound gradi:tally extends upwards, and becomes more pronounced. 

 Sometimes the transition from the dull to the healthy sounding parts 

 ^s so abrupt that a horizontal line will exactly divide them, and this, 



8 . : . . , 



