280 DISEASES OF THE PLEURA. 



thoracic wall, to that produced by the enlarged liver, is immediate ; 

 whereas a small yielding interval is usually discoverable between the 

 border of the ribs and the surface of a liver which has been displaced 

 downward. 5. In enlargement of the liver, the lower ribs not unfre- 

 quently are somewhat bowed outward, the intercostal spaces, how- 

 ever, still remaining uneffaced, excepting in the rare instances in which 

 a huge cyst of echinococci, or an abscess of the liver projecting far into 

 the thoracic cavity, lies in contact with the side of the chest. 



The main point of distinction between a small pleuritic effusion of 

 the left side and an enlarged spleen consists in the change which 

 takes place in the line of dulness during respiration, and which does 

 not occur in pleurisy, but is easily perceptible in enlargement of the 

 spleen. 



Finally, the persistence of the fever, the emaciation and pallor of 

 the patient, may awaken the suspicion that phthisis is developing. It- 

 should not be forgotten that both fever and wasting may be solely 

 dependent upon a latent pleurisy, but the threatening phantom of in- 

 cipient consumption should always be kept in view, and physical ex- 

 ploration of the thorax should be repeated again and again. 



PROGNOSIS. Dry pleurisy is an altogether insignificant affection, 

 nor does pleurisy with scanty sero-fibrinous effusion, of itself, evei 

 cause danger, although the pain which attends it, being a main cause 

 of the dyspnoea, augments the danger from the pneumonia or tubercu- 

 losis, or whatever the primary disease may be. Among the varieties 

 of pleurisy with profuse sero-nbrinous effusion, that which runs an 

 acute course from the outset admits of the most favorable prognosis. 

 When the malady is of a creeping, insidious type, the prospect is 

 much more grave, as, even after complete absorption, tuberculosis fre- 

 quently appears as a sequel. This is also true of empyema when it 

 develops from the foregoing variety, while the effusions which are 

 purulent from the commencement involve a bad prognosis, from the 

 nature of the diseases which give rise to them, namely, septicaemia, 

 puerperal fever, etc. 



Decrease of the effusion is to be regarded as a favorable sign, ip 

 the diagnosis of which, however, we must beware of the sources of 

 error already alluded to. As there is more or less danger from con- 

 sumption in the majority of cases, it is to be regarded as of favorable 

 augury when the patient possesses a vigorous constitution. Finally, 

 the earlier reabsorption commences, so much the more reason have we 

 to hope that the lung may expand again, so that no deformity of the 

 Ihorax may remain behind. 



Symptoms of oedema of the lung and imperfect decarbonization of 

 ihe blood at the commencement of the disease are to be viewed as un- 



