274 DISEASES OF THE PLEURA. 



of the urine (Traube). Distention of the veins leads to cyanosis and 

 dropsy. Finally, owing to obstruction to the outflow from the renal 

 veins, albumen, blood, and fibrinous cylinders frequently appear in the 

 urine. 



In other cases death ensues in consequence of bursting of empy- 

 ema into the lungs, abdomen etc. Death results still more frequently 

 in unabsorbed effusions, in consequence of persistent, although mod- 

 erate, fever, which consumes the organism, and which, therefore, is 

 called hectic. 



Finally, and, indeed, most commonly of all, tedious or imperfect ab- 

 sorption of empyema results in tuberculosis, or in chronic destructive 

 pneumonia, the patient succumbing to the symptoms of consumption. 



PHYSICAL SIGNS OF PLEURISY. When the exudation is scanty, 

 forming a thin membranous coating upon the pleural surfaces, or when 

 it is liquid, and sinks to the more dependent part of the pleural sac, 

 without, however, materially encroaching upon its space, the results 

 of inspection usually are negative. It is only when respiration is ex- 

 tremely painful that we can perceive that the patients spare the af- 

 fected side, and that its respiratory motion is not as free as upon the 

 other side. 8 



When the pleuritic effusion is large, inspection reveals a series of 

 appearances, depending upon the fact that the inner surface of the 

 chest is no longer affected by the traction of the elastic lung (as it 

 should be), but is exposed to the pressure of the exudation. 



1. The intercostal spaces over the area of the effusion are no longer 

 shallow grooves, but are upon a level with the ribs, " they are effaced," 

 and, indeed, are sometimes somewhat prominent. 



2. Where the effusion fills up the entire pleura, the affected half 

 of the chest appears enlarged in all directions, but chiefly in the line 

 of the vertebro-mammillary diameter. When the effusion is not so 

 large, when it is usually incapsulated hi the posterior and lower re- 

 gions of the pleural sac, dilatation of the thorax is limited to the region 

 which contains the effusion. Very much more rarely, incapsulated exu- 

 dations in the pleura produce prominence of some other portion of the 

 thoracic wall. 



3. In effusion of the left side, displacements of the heart can often 

 be made out by inspection alone, and it is the same with displacement 

 Df the liver when the effusion is upon the right side ; in the former 

 jase the impulse of the heart being too low, and too much toward the 

 median line (sometimes, indeed, being perceptible to the right of the 

 sternum) ; in the latter, the right hypochondriac region shows an un- 

 natural prominence. Besides this evidence of pressure from within, 

 exerted bv the effusion upon the surrounding parts, inspection shows 



