1 88 The Pleura 



crevice between the chest- wall and the diaphragm. A sharp instrument 

 may pass through two layers of pleura in the costo-phrenic crevice, 

 and penetrate the diaphragm and liver without wounding lung, and 

 through such a wound a piece of omentum may even protrude. 



The twelfth rib is covered by pleura, and in seeking the kidney 

 from the loin the surgeon, keeping his incision too near to the rib, 

 may open the pleura. 



The apex of each pleura mounts \\ to 2 inches into the neck 

 (p. 164); and over the pleural dome the subclavian artery passes, in a 

 slight groove. 



A peripleuritic abscess is one which forms between the chest-wall 

 and pleura; it is of limited extent, and is obviously very different from 

 an empyema (p. 190). 



Inflammation of the pleura, or pleurisy, causes a 'stitch' in the 

 side, and produces a short cough. As the opposed surfaces become dry, 

 and roughened by fibrinous deposits, they rub against each other during 

 the movements of respiration, and produce * friction-sound or a vibra- 

 tion which may be appreciated even by the touch. The sound is lost 

 as the surfaces again grow moist and smooth, also when they become 

 glued together by plastic lymph, or when they are widely separated by 

 intra-pleural effusion. It is lost also whilst the patient holds his 

 breath, and this distinguishes it from a pericardial friction-sound, 

 which is, of course, uninfluenced by respiration (p. 158). The friction- 

 sound is like that which is often heard with a new saddle. The slower 

 and deeper the inspiration, the more jerky and prolonged the sound, 

 and it may usually be intensified by pressing the parietal pleura nearer 

 to the visceral by thrusting the finger between the ribs. When a class 

 of students are listening for the sound the first comers hear it best, for 

 the deep respiratory movements temporarily smooth down the rough 

 surfaces. 



Movement causes pain, so the affected side of the chest hardly 

 stirs in respiration ; the fellow lung, therefore, does nearly all the re- 

 spiratory work, hurrying to accomplish it. The respiratory movements 

 are, therefore, quick, shallow, and almost unilateral ; they are best 

 noted by placing the hands flat on the ribs ; sometimes one side lags 

 or hardly moves at all. 



The intercostal nerves supply not only the costal pleura, but also 

 the levatores costarum, the intercostals, and the flat muscles of the 

 abdomen. When, therefore, the parietal pleura is inflamed the nerve- 

 trunks are in distress, the patient is neither willing nor able to draw a 

 deep breath, and the utmost rest and comfort are required. The 

 pleuritic patient should not be allowed to converse, as this entails con- 

 siderable respiratory effort. Questions should be arranged so that 

 ' yes ' or * no ' are the only answers needed. 



Sometimes the pleuritic patient has pain and tenderness in the 

 epigastric region, on account of the trunks of the lower intercostal 



