The serous lining of the upper surface of the diaphragm may be involved in an ordinary pleurisy, or inflammation may be limited to it without involving either the pulmonary or the parietal membrane. In this latter case we have modifications of the characteristic symptoms and physical signs. Functional disturbances and special symptoms enable us to diagnose it. There is a febrile movement with occasional delirium, and some of the prominent symptoms, but without the physical signs to indicate the exact locality. The pain is intense, and dyspnoea exists even to the extent of orthopnoea and respiratory anguish, the respiration jerky and convulsive. The pain comes on suddenly in one of the hypochondriac regions, extending up to the attachments of the diaphragm to the costal surfaces. The pain is intense, and increased by full inspirations, by physical efforts, by vomiting, and even by the eructations of wind. The position of the patient attracts attention: as he sits with the trunk inclined forward, he has an anxious and distressed expression of countenance, sometimes accompanied by nausea and vomiting with singultus. Pressure elicits a characteristic tenderness; if applied under the false ribs, it causes suffering. The phrenic nerve is painful on pressure practised over the accessible points of its course, between the two inferior bands of the sterno-cleido-mastoid at the base of the neck. There are also painful irradiations in the cervical plexus above the clavicle and in the scapular region. Pressure over a circumscribed spot of the epigastric region causes a sharp agony of pain. This point is at the intersection of two lines—one, the external border of the sternum; the other, at the osseous portion of the second rib. Guéneau de Mussey186 has named this the diaphragmatic bottom. This pain extends sometimes to the vertebra and upward to the first intercostal space. Auscultation and percussion at the base of the lung give us some results: impaired expansion of the lung at the base and dulness on percussion; the diaphragm is in a great degree immobile, owing partly to the pressure upon it, and partly to a paresis from inflammation of its upper serous covering (Stokes187). When the inflammation is on the right side, we may find an icteroid tint, with vomiting, delirium, etc., with the liver pushed below its normal position in the abdomen. The inflammation of the pleural covering of the diaphragm may be caused by sero-hepatitis extending through the diaphragm (Copeland188).
186 Archiv. de Méd., 1879, vol. ii.
187 Dis. of Chest, 1837.
188 Dict. Med., vol. iii., edited by Lee.
If the effusion is confined to the space between the lung and diaphragm, the diagnosis is obscure. There may indeed be cases where we have but few of the symptoms already mentioned. If the fluid is not confined to this portion, but flows into the pleural cavity, it gives great relief, and the result is favorable. Diaphragmatic pleurisy may, however, end in death, either by its discharge into the peritoneal cavity or by constitutional disturbances.
Interlobular and Mediastinal Pleurisies.
The effusion is sometimes confined by adhesions between two lobes. The mediastinal variety is situated between the pleural boundary of the mediastinum and the adjacent portion of the pulmonary serous membrane. It is but rarely met with, and may be diagnosed by local symptoms. The flatness on percussion in the interlobular variety is very circumscribed. Both forms cause local pains, but in the mediastinal variety the pain is very deep and perceptible at the middle of the sternum, and is increased by the respiratory movements. In both varieties there is more or less fever. If either variety exist on the left side, the condition of the pericardium must be carefully examined, as pericarditis may be confounded with it. These limited collections of fluid may burst into a bronchus and be expectorated.
Multilocular Areolar Pleurisies.
Multilocular encysted collections of fluid in the pleural cavity are due to the partitions made by pseudo-membranes which divide the pleura into subcavities. These occur generally in subjects who have had previously dry or adhesive pleurisies. They are more serious than ordinary pleurisies. We meet with them in aspirating, when, after draining off the fluid from the base of the pleural cavity, we find the lung expanding, but above that point there is absence of respiratory murmur and of other physical signs indicating the presence of fluid. Reybard189 divides multilocular pleurisy into three varieties, with varying symptoms and physical signs, according to whether it exists at the upper, middle, or lower portion, right or left side. Owing to the thickness and distribution of neo-membranes, it is frequently difficult to localize the points of collections of fluid. Aspiration is the most accurate means of ascertaining the exact point and extension of the effusion.