Fluid in Pleura 



189 



nerves being implicated. Such peripheral pains are like those met 

 with in lower dorsal caries, but they are not usually bilateral. If pain 

 extend into the armpit or down 

 the inner side of the arm, the 

 explanation is to be sought in 

 the distribution of the lateral 

 cutaneous branches of the inter- 

 costal nerves, and especially of 

 the intercosto-humeral. 



Hydrothorax. As the re- 

 sult of pleurisy, serum oozes from 

 the capillaries of the pleura into 

 the cavity, rilling, perhaps, one 

 side of the chest, but hydrothorax 

 is apt to occur in disease of heart 

 (p. 178) and of kidney. The fact 

 of the pleura being a large lymph - 

 space accounts for the rapid ab- 

 sorption which 'water in the 

 chest' sometimes undergoes. If 

 there be only a small amount of 

 fluid in the chest there is a dull 

 percussion note behind as the 

 man lies supine, but as he is 

 turned on to his face the dulness may shift its position. As he sits up 

 the dull area is just above the diaphragm, front and back, the lung being 

 floated up. When the pleura is choke-full the intercostal furrows of 

 that side are effaced, the lung is driven into the costo-vertebral groove, 

 and the heart, as shown by the position of the apex-beat (p. 162), is 

 displaced right or left, as the case may be. The lung being com- 

 pressed, that area is absolutely dull on percussion ; the gentle breath- 

 sounds are lost, and the water-logged side of the chest scarcely moves 

 with respiration ; the air may be heard at the back, however, entering 

 and leaving the rigid tubes (bronchial respiration, p. 200). There is a 

 general bulging of that side of the chest. The patient obviously prefers 

 to be upon the heavy side ; and, as he speaks, the hand placed on the 

 chest detects absence of "vocal "vibration, for the fluid cuts off all the 

 sound-waves. The lung does not float on the fluid. 



Some of the above signs equally apply to a solid thoracic tumour, 

 but a solid growth does not cut off the vibrations a wooden carriage- 

 seat transmits vibrations, a water-cushion dissipates them. 



In the case of effusion the liver and spleen are driven from the 

 shelter of the ribs and may be brought within reach of the fingers. The 

 full pleura may also bulge below the clavicle or in root of neck. 



In left hydrothorax, as the diaphragm and phrenic pleura are 

 lowered, the pericardium, which is attached to the central tendon, also 



Heart displaced vertically and to the right by 

 effusion into left pleura. (BRAUNE.) 



