Pleurisy with effusion

Effusion may develop insidiously or it may follow or be accompanied by pleuritic pain. Fluid, in considerable quantities, can accumulate without symptoms if it collects slowly and the patient is thus given time to adjust to its presence gradually. On the other hand, it may sometimes accumulate with great rapidity, in which case distress and dyspnoea may become urgent.

The physical signs of fluid, whether it be transudate or exudate, pus, chyle or blood, are characteristic and, provided that the quantity is sufficient, unmistakable. The apex beat is displaced away from the fluid, movement on the affected side is reduced, and there is decrease in tactile fremitus and impairment of percussion note on the side of the fluid. The impairment of percussion note is so striking that the word " stony " has come to be associated with this type of dullness, and eliciting the physical sign may often cause pain in the fingers of the percussor. The breath sounds are absent or altered in strength and may, in certain circum­stances, be bronchial. Added sounds are no part of the picture unless there be a rub at the upper limit of the fluid. The spoken voice often takes on that peculiar nasal quality known as " aegophony ". Physical signs are found in the presence of moderate or large collections of fluid, but if the fluid is confined to an inter­lobar fissure or is less than 150 millilitres approximately in total amount in an adult, it may be unrecognizable by physical examination.

Fluoroscopy will show gross collections of fluid immediately. The affected part of the thorax is poorly lit and the illumination does not improve with inspiration. Turning the patient slowly into the lateral and oblique positions may help to define the extent of the fluid, and the lordotic view will generally show involve­ment of the greater fissure. The x-ray plate provides further evidence and a permanent record. Fluid gives a shadow as opaque as the heart shadow and diaphragm, with which, according to the amount which is present, it merges. A well penetrated view may show its distribution but, despite the older teaching on the subject, the upper limit of the fluid does not invariably run in a gentle curve towards the axilla, and change of posture only slowly brings about re-distribution in the closed pleural cavity, too slowly to permit regular and convincing demonstration of shifting dullness (Figs. 1-3, la and b).