A Study of Diaphragmatic Pleurisy. 
BY 
Chief of Clinic for Throat and Chest, University of Maryland, and late Scholar in Biology, 
Johns Hopkins University. 
FRANK DONALDSON, Jr., B. A., M. D., 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. 
April, 1886. Extracted from the 
American Journal of the Medical Sciences for April, 188fuj 
A STUDY OF DIAPHRAGMATIC PLEURISY. 
By Frank Donaldson, Jr., B.A., M.D., 
CHIEF OF CLINIC FOR THROAT AND CHEST, UNIVERSITY OF MARYLAND, AND LATE SCHOLAR IN BIOLOGY, 
JOHNS HOPKINS UNIVERSITY. 
A case of diaphragmatic pleurisy which came under the writer’s 
observation, some months since, attracted his attention to this very rare 
disease, and forms the basis of this study. 
Diaphragmatic pleurisy seems to have been known to the ancients in 
a general way. They describe it under many different names, as phre- 
nitis, paraphrenitis, diaphragmitis, etc. Under these names they 
included several distinct affections, which had, however, the common 
symptoms, fever and delirium. Hippocrates1 used the term phrenitis, 
but as designating a febrile state only, and not as indicating any disease 
of the diaphragm itself. 
Oelguinetus and Tralian, however, seem to have known true phrenitis 
or inflammation of the diaphragm, for they speak of the distinct type 
of the respiratory movements in the latter affection—a type which they 
failed to notice in ordinary phrenitis, or delirium with fever. 
The term paraphrenitis (first used by Rufus, of Ephesus,2 a contem- 
porary of Galen) had a more definite signification, and was applied by 
him to actual or supposed inflammation of the diaphragm where the 
brain was affected symptomatically. This author states that the partition 
which divided the organs of the chest from those of the abdomen was 
called Siadpay/ia or Opeveq (the soul), the ancients supposing the seat of the 
soul to be in the diaphragm, and he goes on to say, that as the term 
phrenitis was used to describe several distinct affections, he proposes 
that inflammation of the diaphragm should be designated as paraphre- 
nitis, simply to prevent confusion. Galen3 also knew diaphragmitis as 
a distinct affection, and in a chapter entitled “ Phrenitis from inflamma- 
tion of the brain, and that from inflammation of the diaphragm,” describes 
the delirium which follows inflammation of the brain, of the lungs, and 
of the pleura, and remarks that inflammation of no other organ causes 
1 The Works of Hippocrates, by Francis Adams, Sydenham Society, 1849, vol. i. p. 418. 
2 Rufus, of Ephesus, De Corpor. Human.-, lib. i. 3 De Locis atfectis, lib. v. cap. v. 2 
DONALDSON, DIAPHRAGMATIC PLEURISY. 
such continued delirium as that of the diaphragm. This writer, however, 
placed the seat of the inflammation in the muscular structure of this 
partition, and not in its serous covering, though he none the less accu- 
rately described the peculiar character of the respiration, and the retrac- 
tion of the hypochondriac region, always present in this malady. 
Wolffius1 (1661) also recognized this disease as a distinct affection, 
and gives its symptoms in more or less detail. Following the last writer, 
Boerhaave2 gives a complete description of diaphragmatic pleurisy, under 
the name paraphrenitis, recognizing it as an inflammation of the serous 
covering, viz.: “Si morbus pleuritidi similis occupat earn membranoe 
pleurae partem quae diaphragma ambit, vel et ipsum septum medium ; 
paraphrenitidem appellant.” 
Huxam3 goes further, and describes both primitive and secondary 
inflammation of the diaphragm. Morgagni4 gives the case of a man 
who having escaped inflammation of the lungs, was taken with “ a 
pleuro-peripneumony, which was succeeded by a phrenitis, and even by a 
paraphrenitis,” and explains at length the exact sense in which the latter 
term is used by him, and declares that he does not wish to be understood 
as saying that the delirium (phrenitis) in this case necessarily depended 
on inflammation of the diaphragm. Sepulchretus5 gives two observa- 
tions of inflammation of the diaphragm, one from Blasius6 and the other 
from Laelius a Fronte. The latter saw the diaphragm actually sup- 
purated, and the former greatly inflamed after a phrenitis. Finally, 
Schneider7 wrote quite fully on inflammatory affections of the diaphragm. 
With this author our history of the subject is brought down to the 
eighteenth century. During this hundred years our practical knowledge 
of diaphragmatic pleurisy cannot be said to have increased, though an 
enormous amount was written on the subject. I find, after careful 
search, some twenty-two distinct treatises of more or less scientific value 
written between 1700 and 1800, but I shall allude only to the more im- 
portant of these monographs. Selle* seems to have been the first to use 
the term diapliragmitis, and, moreover, he gives the signs and symptoms 
of the disease with unusual clearness. Stoll9 gives not only the general 
symptoms of the disease, but two cases thereof, observed by himself, with 
the post-mortem appearances. Lieutaud,10 writing in 1767, gives three 
cases of diaphragmatic pleurisy, taken from De Haen,11 and Cullen12 
1 De Septi Transversi Inflammatione ; Argentorati, 1661. 
2 Apbor. de Cognos. et Curand. Morb., 1709. 
3 Essay of Fevers, 1747. 
4 De Sedibus et Causis Morborum. Translation of Dr. John Alexander, London, 1749, book I. letter 
vii. art 14, p 139. 
6 Anat. Fraetica ex Cadav. Morbo denati. Edited by Theo. Boult, Geneva, 1679. 
6 Misc. Anatomica, etc , liber I. sec. i. obs. i , Amstelodami, 1673. 
i De Inflam. Diapbragmatis, Wittenberg, 1665. 8 Rudimenta Pyretologie, p 170. 
9 Radio Medendi, 1777, p. 345. 10 Historia Anat Medica, vol. i. p. 95. 
n Radio Meden part I. p. 84, and part IX. p. 17. 12 Elements of Practical Medicine, 1784. DONALDSON, DIAPHRAGMATIC PLEURISY. 
3 
directs particular attention to the disease, as involving not the muscle, 
but the pleura which covers it. 
It was not, however, until the early part of the present century, after 
Bichat’s researches, that inflammation of the serous coverings in general, 
and the diaphragmatic pleura in particular, attracted general attention 
to the part played by the latter in the causation of the disease before us. 
Portal1 wrote that inflammation of the diaphragmatic pleura was by 
no means so rare a disease as was formerly supposed. Pierre Frank,2 
though he gives a number of the characteristic symptoms of this affec- 
tion, confounds it with pleurisy proper and peritonitis. Boy,3 in de- 
scribing the risus sardonicus, declares it to be a constant symptom of 
inflammation of the diaphragmatic pleura. Laennec,4 in the first edition 
of his work, describes inflammation of the diaphragm under the general 
head of circumscribed pleurisies. He declares the former to be a very 
rare and grave disease, but gives no definite diagnostic signs. Buffinton,8 
again, gives the symptoms of this disease, and says the malady is always 
fatal. This brings us to Andral,9 who was the first to publish definite 
observations under the name of diaphragmatic pleurisy, and to show that 
the affection might be primary or secondary. He gives five cases in his 
Clinique Medicale,7 and divides the symptoms into four groups, viz., 1st, 
the pain, increased by pressure, along the cartilaginous border of the 
false ribs, and extending down and outward; 2d, the almost complete 
immobility of the diaphragm; 3d, the expression of the countenance; 
and, 4th, the constant orthopncea, with forward inclination of the body. 
To Andral must be given the credit of giving this disease, with its signs 
and symptoms, a definite place in medical literature. A number of 
authors after Andral wrote on this subject with more or less fulness 
and accuracy, Joseph Frank8 more particularly giving much space to it. 
He adopted, however, the idea and nomenclature of the ancients, in spite 
of his acquaintance with Andral’s advanced treatise. Mehliss9 also wrote 
at some length on inflammatory affections of the diaphragm, but it re- 
mained for Gueneau de Mussy,10 in 1853, to write the first elaborate mono- 
graph on diaphragmatic jdeurisy, and the great importance of this work 
will be seen further on in our paper. I find a number of other articles on 
the subject, published from 1853 to the present date, reference to which 
will be found in the text. 
So much, for the history of our subject, and before treating it more 
in detail, I give briefly my own case, which I wish to put on record: 
1 Anatomie Medicale, 1803, vol. iv. p. 233. 
2 I)e Cur hominum Morbis Epitome, 1812, lib. ii. p. 179. 
3 Traite sur le rire, Paris, 1814. 4 Traite de 1’auscultation Mediate, Paris, 1819. 
6 Paris Thesis, 1822. 6 Arch, de Medecine, October, 1823. 
1 Clinique Medicale, Paris, 1824, vol. i. p. 480. 8 Pathologie Medicale, vol. iv. p. 371. 
9 Anat. du Diaphragm, chez l’homme, 1845. 10 Archives de Medecine, 1853-54. 4 
DONALDSON, DIAPHRAGMATIC PLEURISY. 
The patient, a man of about forty-one years, was brought to our office, 
in the words of his physician, “ for a diagnosis.” He had been sick for 
nine weeks; his illness had begun with a chill, followed by intense pain 
referred to the lower intercostal region, more particularly on the right 
side over the liver, with great and increasing difficulty of respiration. 
He had been, almost from the first, unable to lie down, sitting always 
with the body bent forward, and his hands pressed to his side to pre- 
vent any extra motion. His cough was incessant and dry, his dyspnoea 
and anxiety of countenance, even at this time, painful to behold. 
Though I had never seen a case of diaphragmatic pleurisy, I was led 
to suggest that the trouble was with this structure even before making 
a careful examination, for I knew of nothing which could produce the 
peculiar distinctive respiration, found in this patient, except some trouble 
of the diaphragm. 
On examination, the abdomen was found retracted, the diaphragm 
almost immobile, and the respiration entirely costal. There were 
points anteriorly and posteriorly painful to pressure. On percussion, 
some dulness was observed around the lower part of the chest, especially 
on the right side behind. On auscultation, pleural friction sounds were 
heard on the left side only; on the right, feeble respiratory murmur, with 
subcrepitant rales in a circumscribed space at the base of the lung, the 
inflammation having extended from the diaphragm to the lung and set 
up a localized pneumonia. 
Such being the signs and symptoms in the case, a diagnosis of dia- 
phragmatic pleurisy of tubercular origin, with slight effusion on the right 
side, was made by my father, Prof. Donaldson. It only remains to say 
that the patient grew gradually worse, the spot of pneumonia was not 
resolved, and his lung began to break down. Owing to the great pain 
that any movement of the diaphragm gave him, he was able to expec- 
torate to a limited extent only, which increased his sufferings and hast- 
ened his death. 
When we consider the structure and position of the diaphragm, the 
number of vessels and nerves which pass through it, the organs to 
which it is adjacent, and the three serous coverings with which it is con- 
nected, its pathological importance is apparent, and it is a matter of 
surprise that so little attention has been given it as the seat of disease. 
Primary inflammation of the musculo-tendinous structure of the 
diaphragm is very rare, though it occurs in the course of acute rheuma- 
tism, in penetrating wounds, and in injuries of the chest. Inflammation 
of the diaphragmatic pleura is much more frequent, and is caused by 
pleurisy, pneumonia, hepatitis and peritonitis, wounds of the chest and 
abdomen, fracture of the lower ribs, blows at the base of the chest, cur- 
rents of cold air on the perspiring body, immoderate laughter, continued 
crying and weeping, the suppression of rheumatism (Patterson,1 Portal2), 
the healing of old sores (Aaskou,3 Boisseau,* Selle5). Hildebrand8 con- 
siders tight lacing and corsets a cause of this disease. 
1 Trans, of Med Soc. of London, vol. v. No. 32. 2 Loc. cit. 
3 Acta Soc. Med., Havana, t. i. p. 205, 1777. 
4 Nosographie Organ, t x. p. 620. 6 Loc. cit. 6 Institutions M6dicale, t. iii. p. 267. DONALDSON, DIAPHRAGMATIC PLEURISY. 
5 
Diaphragmatic pleurisy would seem to be most frequent in the adult 
and in women. It is rare in children, though I find cases reported 
respectively by Graves,1 Hildebrand,2 and one by Jacubuscli3 of an in- 
fant but five months old. Diaphragmatic pleurisy is more often uni- 
lateral, both sides, however, being affected indifferently. Just here it 
should be stated that beside the primary inflammation of the diaphrag- 
matic pleura spoken of above, there is a form of so-called acute benign 
diaphragmatic pleurisy, first written of at length by Bucquoy,4 the 
tendency of which is always toward cure, and of which I shall treat 
fully later on. 
Secondary inflammation of the diaphragm, though generally over- 
looked, is none the less frequent. It is most often caused by tuberculosis, 
and is invariably fatal5 (Andral,6 Peter,7 Howe8). It occurs also in 
those recovering from acute rheumatism (Patterson, Portal, Dubois,9 
Peter10). It is usually double and not necessarily fatal. General or 
partial peritonitis often lights up a secondary inflammation of the dia- 
phragm (Peter,11 Cutler,12 Foix13 ); and Herndon14 relates a case of perfora- 
tion of the diaphragm following severe peritonitis. Pitres15 and Lance- 
reaux16 were the first to call attention to puerperal peritonitis as a cause 
of diaphragmatic pleurisy; this form of the malady is always fatal. Char- 
rier,17 also, in relating the epidemic of puerperal peritonitis observed at 
the Maternity Hospital, remarks on the frequent coexistence, in such 
cases, of inflammation of the diaphragmatic pleura. Hervieux,18 Hilton 
Fagge,19 Foix,20 Laroyenne,21 Coyne,22 and others, all remark the frequent 
production of this disease by puerperal peritonitis, agreeing that -the 
inflammatory products are usually carried by means of the lymph chan- 
nels, and that the pleurisy is caused directly by a peritoneal abscess which 
breaks through the diaphragm. 
As to the so-called epidemics of diaphragmatic pleurisy observed by 
Sagar in 1770, and by Boerhens in 1819, it may be said that the epi- 
demics in question wele most probably typhoid fever with peritonitis, 
followed by inflammation of the diaphragmatic pleura. Finally cysts, 
abscesses, and cancer of the abdominal viscera are often the direct cause 
of a diaphragmatic pleurisy. 
1 Clinical Medicine, 1863, vol. ii 
2 Journ. f. Kinderkrankheiten, 1854, vol. xxii. p. 412. 
3 Berlin, klin. Wochensclir., Oct. 8, 1883. 4 Lemons Clinique, Paris, 1873. 
5 Chauffaud in Ilerniil. Paris Thesis, 1879, p. 98. 
6 Loc. cit. 7 Gaz. des Hop., 1875, p, 1065. 
3 Med. Journ. and Gazette, Feb. 1857. 9 Paris Thesis, 1876. 
10 Arch. General, de Med., 1871, p. 343. n Union Medicale, 1856, p. 562. 
12 Bull, de la Soc. Anat., 1874, p. 197. 13 Paris Thesis, 1874. 
14 Wien. med. Presse, 1869, x. p. 990. 16 Bull, de la Soc. Anat., 1875. 
10 Pro. Med. Francaise et etrangere, 1879, p. 474. U Paris Thesis, 1855. 
13 Traite clin. et prac. de mal. puerperale, Paris, 1870. 
19 Guy’s Hospital Reports, 1879, vol. xix. 20 Loc. cit. 
21 Lyons Med., 1877. 22 Bull. Med. du Nord, 1877. 6 
DONALDSON, DIAPHRAGMATIC PLEURISY. 
As to the frequency of this disease, it must be confessed that it is not 
very rare. Laurence, Andral, Peter, and de Mussy think it by no 
means uncommon. It is impossible to give the exact number of cases 
on record; speaking generally, it is less than one hundred. Doubtless 
its apparent rarity arises from a failure on the part of physicians to 
recognize the disease, or, when diagnosticated, to put on record. 
Symptomatology.—The onset of diaphragmatic pleurisy is variable. 
It is usually ushered in by a chill of greater or less violence, followed by 
fever and sweat. Secondary pleurisy, arising in the course of acute 
or chronic disease, is marked by an increase of the fever or by a distinct 
chill; but it is the pain and the characteristic symptoms which follow, 
that attract attention. In perforation of the diaphragm by bursting of 
an abscess of the liver, for instance, violent pain and dyspnoea are the 
prominent symptoms. Intense pain in the side and constriction of the 
lower part of the chest, soon follow the chill. The pains of diaphrag- 
matic pleurisy are characteristic, and are to be referred to the terminal 
filaments of the phrenic nerve; they are what Hermil calls “ douleurs 
par propagation.” 
If we call to mind the anatomy and distribution of the phrenic nerve, 
we can explain many of the peculiar symptoms found in inflammation of 
the diaphragmatic pleura. It arises from the third and fourth cervical 
nerves, receiving a branch from the fifth, and runs through the chest to 
the diaphragm, where it divides into branches which pierce that muscle 
separately, and are distributed to its upper and under surface. The nerve, 
besides its connection with the nerves of the neck and shoulder, supplies 
filaments to the pericardium and pleura; near the chest it is joined by a 
filament from the sympathetic and by one from the fifth and sixth 
cervical nerves. It is also connected with the solar and hepatic plexuses, 
and gives off filaments to the peritoneum and the suprarenal capsules. 
The pains of diaphragmatic pleurisy extend, as might be expected, over 
a large surface—over the whole hypochondriac region and over both 
flanks to the inferior dorsal region behind, following the line of the 
costal insertions of the diaphragm, and often along the border of the 
sternum and under the lower insertion of the sterno-cleido-mastoid 
muscle, and over the shoulder and neck. The pains may be spontaneous, 
but are always evoked by pressure or by increased respiratory movements, 
hiccough, vomiting, etc. According to de Mussy,1 the favorite seats of 
pain on pressure are over the epigastrium, at the points of insertion of the 
tendons of the diaphragm ; in the last intercostal space behind, near the 
spine; along the course of the phrenic nerve ; and, finally, at what he calls 
“ le bouton diaphragmatique,” where the pain is always especially great. 
De Mussy localizes this spot at a point one or tvro fingers’ breadth from 
1 Arch. General, de Medecine, 1853, vol. ii. p. 274. 7 
DONALDSON, DIAPHRAGMATIC PLEURISY. 
the middle line, on a level with the tenth rib, or at the intersection of a 
line drawn from the osseous part of the tenth rib and one drawn along 
the border of the sternum. He explains the greater pain at this point 
by the greater play of the rib and consequent friction against the in- 
flamed nerve. 
The pressure of the liver and spleen on the inflamed pleura serves to 
explain the pain felt over these organs. The pain along the trunk of 
the phrenic nerve, referred to above, is rarely spontaneous, but is always 
evoked by pressure, and especially is this so at the point where the nerve 
runs under and between the inferior division of the sterno-cleido-mastoid 
muscle.. He Mussy gives a case where great pain was spontaneous at this 
point. This hypersensibility of the phrenic nerve is explained by its 
partaking of the inflammation of the diaphragm. Pressure in the inter- 
costal spaces also gives rise to pain. The pains of propagation—the 
reflex pains—run along the sides, downward even to the iliac fossa, but 
are usually more intense in the upper part of the body. They are some- 
times felt with special intensity in those muscles connected by their nerves 
with the cervical and brachial plexuses. Supraclavicular pains are gen- 
erally severe, as well as those in the shoulders and over the scapula and 
the trapezius muscle generally, the nerves of this entire region being con- 
nected through the fourth cervical with the phrenic, as we have stated. 
The pain referred to the axillary region comes from the connection of 
the phrenic with the internal cutaneous and the brachial plexus. 
Hypersensibility of the phrenic nerve is also sometimes observed in 
inflammation of the costo-pulmonary pleura and in pericarditis; and it 
sometimes precedes acute inflammation of these organs and of the dia- 
phragm. Absence of spontaneous and provoked pain at the various 
parts mentioned was noticed by Graves;1 and, indeed, in his case pressure 
upon the painful spots relieved the pain. It seems that in cases of 
double diaphragmatic pleurisy the pain is always greater on one side 
than the other. As to the frequency of pain in any given place, that in 
the hypochondriac region is most often present. In 40 cases given by 
Hermil, visceral pain was present in 15 cases, special pain at the 
“bouton diaphragmatique” in 9 cases, pain under the sterno-cleido- 
mastoid muscle in 20 cases, supraclavicular pains in 7 cases, in shoulder 
11 cases, and pains in the axillary region in 2 cases. 
The attitude of a person with diaphragmatic pleurisy is very charac- 
teristic : The dorsal position being impossible, the body is bent forward, 
and the hands are applied to the sides in order to immobilize the dia- 
phragm as much as possible. The expression is one of great anxiety 
and suffering; this peculiar pinched, painful look is more marked where 
there is a coexistent peritonitis. The convulsive movement of the 
1 Lou. cit. 8 
DONALDSON, DIAPHRAGMATIC PLEURISY. 
muscles of the face and mouth, the rums sardonicus, is often present, 
though it is not, of course, as was formerly supposed, a diagnostic symp- 
tom of this disease. The most distinctive and prominent symptom in 
diaphragmatic pleurisy is the frequency and shallowness of the respi- 
ratory movements. They are short, aborted, and accompanied with 
great pain and discomfort to the patient. Inspiration is entirely costal 
and limited, even then, to the upper part of the chest; and, indeed, it 
may be limited to one side, as in a case given by de Mussy. The num- 
ber of respirations is, of course, greatly increased, running as high as 
80 or 100 (Hayden1 and Graves2). The great trouble and pain in 
breathing arise, of course, from the interruption in the play of the 
inflamed diaphragm, kept immobile either by the patient himself, or by 
a complete or partial paralysis of the structure itself. Paralysis of the 
diaphragm in such cases is caused directly by the inflamed condition of 
its pleural surface (a condition somewhat akin to the paralysis of the 
palate following diphtheria, Stokes),* or by a compression of the phrenic 
nerve by the fibrinous exudation. Again, although there may be no 
paralysis as such, the effusion may be so large as greatly to embarrass 
diaphragmatic action. The immobility of the diaphragm in these cases, 
from whatever cause, is an interesting and instructive symptom, and is 
the direct cause of the retraction of the hypochondriac region invariably 
seen in diaphragmatic pleurisy. This sign was held by Galen and the 
ancients as pathognomonic of this disease. Selle4 remarks it, and Van 
Swieten6 speaks of the quiescente abdomine. The diaphragm being to a 
great extent immovable, it forms a more or less elastic division between 
the chest and abdomen, the movements of which are in opposition to each 
other, and are exactly the reverse of those of normal respiration. The 
paralyzed diaphragm is an inert partition, which follows the respiratory 
movements instead of directing them. 
Paralysis of the diaphragm, however, is rarely complete and usually 
unilateral, and in most cases the immobility of the diaphragm is due to 
the pain caused by any superfluous movement. Of course, the effusion 
may be so great as to cause not only a paralysis, but a complete sagging 
of the diaphragm, and great displacement of all the abdominal organs, 
as in a case of pyopneumothorax seen by the author. 
Respiration being so much impeded, auscultation gives very negative 
results. Great enfeeblement of the respiratory murmur on the affected 
side, a few subcrepitant rales at the base of the lung from its imperfect 
expansion and involvement in the inflammation of the adjacent pleura, 
and pleural friction sounds over the diaphragmatic area, are the only 
signs present to the ear. Laennec declared icgophony to be present in 
1 Dublin Quarterly Journ., 1871, vol. lii. * Loc. cit. 
3 Dublin Quarterly Journ., 1836 * Loc. cit. 
6 Comraenturia in Aphor. Boerbaave, vol. ix., 1771. DONALDSON, DIAPHRAGMATIC PLEURISY. 
9 
diaphragmatic pleurisy on theoretical grounds, and the experience of 
Skoda would seem to confirm the statement. More or less dulness im- 
mediately around and above the diaphragm is present on percussion. 
The cough is frequent, dry, and exceedingly painful; the expectora- 
tion slight and thin. Where the inflammation extends to the costo-pul- 
monary pleura, we have, in addition, all the signs of this affection. In 
cases of diaphragmatic pleurisy with effusion, de Mussy gives, as an 
important symptom, the lowering of the twelfth rib, so that its anterior 
end is lower than that of the twelfth rib on the opposite side. This sign 
is given by Chauffaud in a case quoted by Hermil.1 In cases of effusion 
there may be slightly increased Skodaic resonance on percussion over the 
attachments of the diaphragm. 
Hiccough is often a distressing symptom in this malady, and was at 
one time considered diagnostic. It has no absolute value, however, for 
it is also present in circumscribed peritonitis of the superior part of the 
abdomen. Sometimes it is present from the very beginning in inflam- 
mation of the diaphragm ; Vergely'7 gives such a case, which was rapidly 
fatal. Nausea and vomiting, too, are often extreme, and icterus has 
been noticed in two cases of right diaphragmatic pleurisy by Hermil,3 
and also by Andral* and Monod.5 It is, of course, caused by the exten- 
sion of the inflammatory process from the diaphragm to the liver. 
Dilatation of the stomach has been met with by Peter,6 who was the 
first to call attention to it as a complication of this disease, and also by 
Laporte.7 It proceeds from an inflammation of the peritoneal covering 
of the stomach, which later invades the muscular structure of this organ, 
causing it to lose more or less of its tonicity, and to be easily distended 
by gases, etc. Violent pain when a bolus of food passes the oesophagus 
at its passage through the diaphragm is a symptom sometimes met with 
in diaphragmatic pleurisy. 
Great delirium is often present, though it is not an essential symptom 
of this disease, as was formerly supposed. That it is present more often 
in this malady than in costo-pulmonary pleurisy is explained by the 
greater dyspnoea and want of aeration of the blood. Coma sometimes 
sets in at once, in which case the disease runs rapidly to a fatal termin- 
ation. The pulse is small and rapid. The temperature runs usually 
from 38° to 393 Centigrade, though it rises much higher when the 
diaphragmatic inflammation is complicated with some other malady. 
The course of diaphragmatic pleurisy is variable. In primitive 
cases the invasion is rapid, the symptoms reaching their greatest intensity 
quickly, and subsiding in the same manner. Double pleurisy rarely 
1 Loc. cit., p. 98. 2 Gaz. des HOp , 1873. 
3 Loc. cit. * Loc. cit. 
6 Hermil, p. 77. 
6 Clin. Med., yol. i. p. 400, and Journ. de pract. rued, et Chir., 1874, p. 299. 
7 Paris Thesis, 1869. 10 
DONALDSON, DIAPHRAGMATIC PLEURISY. 
begins as such, one side being affected first. Secondary pleurisy is often 
complicated by pericarditis, peritonitis, etc., and generally ends fatally. 
The duration, too, is variable; the acute symptoms are more prolonged 
than in ordinary pleurisy. The neuralgic pains along the course of the 
phrenic nerve often continue for a long time, with tenderness over the 
insertions of the diaphragm. 
Diagnosis.—The diagnosis of diaphragmatic pleurisy is at best diffi- 
cult and uncertain; and unless great care be taken, the disease will pass 
unrecognized. The diagnosis cannot be founded on any one particular 
sign or symptom. Andral went so far as to say that inflammation of the 
diaphragm might exist without being announced by any characteristic 
symptom. De Mussy, however, holds that by careful differentiation we 
may always arrive at a satisfactory diagnosis. He lavs great stress on 
the value of the “diaphragmatic button,” for in no other malady does 
pressure on this particular point cause pain and dyspnoea. The prominent 
symptoms, then, to be looked for, are spontaneous and provoked pains in 
the places and regions already described ; immobility of the abdominal 
walls and the epigastric “hollow;” the peculiar type of respiration ; dul- 
ness on percussion over the diaphragmatic area; pleural fremitus; ab- 
sence of respiratory murmur; hiccough; vomiting; pleuritic cough, etc. 
Nearly all the authors, from Galen to Joseph Frank, have discussed the 
relation between diaphragmatic pleurisy and pleuritis or meningitis. 
Morgagni1 and De Haen2 give observations to prove that delirium may 
be entirely absent in the former disease. Joseph Frank3 goes further, 
and declares that delirium and sardonic laugh belong no more to this 
affection than to inflammation of other organs. De Mussy, however, 
thinks (as do most observers) that delirium is more frequent in diaphrag- 
matic than in costo-pulmonary pleurisy. Again, the absence of the 
positive signs and symptoms of disease in other and adjacent organs, must 
be well noted. In cases of greater or less effusion, the diagnosis is less 
difficult, because of the displacement of the liver and spleen, and of the 
abdominal organs generally. 
Acute diaphragmatic pleurisy is to be differentiated from 
I. Rheumatism of the diaphragm. Rheumatism of this structure is 
pyretic, the fever gradually increases for from one to eight hours,4 and 
the acute symptoms terminate spontaneously and without complica- 
tion. It is unaccompanied by pain on percussion at the points described 
above, the pain being limited to the insertions of the diaphragmatic 
muscle.5 
II. Inflammation of the muscular structure of the diaphragm itself. 
Such a diagnosis it is almost impossible to make, though it is to be re- 
1 Loc. cit. 2 Loc. cit. 3 Loc. cit. 
4 Chenevier, Gaz. dos Hop., 1858. 
6 Fernet, N. Diet, de med. et Chir. prat , Paris, 1869, xi. 344. DONALDSON, DIAPHRAGMATIC PLEURISY. 
11 
membered that the latter is a very rare affection, and results from 
wounds or abscesses only. 
III. Neuralgia of the diaphragm, which in itself is often a symptom 
or result of acute inflammation of the diaphragm. When it is present, 
we must get at its cause, whether it is dependent on some affection of the 
heart, or great veins, or on anaemia, hysteria, etc. The absence of fever, 
however, the side affected, and the intensity of provoked pains will 
greatly assist in diagnosis. 
IV. Costo-parietal pleurisy. In this disease, though the pain in the 
side is as great as in diaphragmatic pleurisy, the seat of the pain is 
higher up, and, above all, it is accompanied by the well-known per- 
cussion and auscultatory signs which are wanting in diaphragmatic 
pleurisy. Of course, they may and do exist together. Peter1 gives a 
case of diaphragmatic pleurisy with encysted effusion in a phthisical 
patient which was overlooked and mistaken for caseous pneumonia on 
account of the compression of the lung by the fluid. 
V. Pericarditis. In pericarditis we sometimes have pain along the 
course of the phrenic nerve; when such pain is present, however, the 
heart affection is complicated by some other disease, as in a case recorded 
by Bouillaud2 of a pericarditis with purulent pleurisy, involving the 
diaphragm. De Mussy gives the differential character of the pain in dia- 
phragmatic pleurisy and pericarditis somewhat as follows: Whereas, in 
the former the principal point of pain is in the “ bouton diaphragmatique,” 
on the right side, in the latter it is in the costo-ziphoid angle, on the left 
side, and immediately under the zrphoid appendage. The dyspncea, too, 
is much less in pericarditis, and the physical signs on auscultation and 
percussion are distinctive, though the pericarditis may be concurrent 
with an inflammation of the left side of the diaphragm; eight such cases 
are reported by Hermil. 
VI. Hepatitis. Right diaphragmatic pleurisy, with icterus, bilious 
vomiting, and displacement of the liver, may naturally be mistaken for 
acute hepatitis, which last, however, is a very rare disease with us. In 
it there are no painful points as in pleurisy, no great dyspncea, no diffi- 
culty in the dorsal position ; further, the pain produced by the pressure 
of the enlarged liver on the diaphragm is distinct from that produced 
by inflammation of the diaphragm itself. 
VII. Circumscribed peritonitis of the superior part of the abdomen. 
A differential diagnosis in this case is often very difficult, for the affec- 
tions have in common the superficial pain over the abdomen, increased 
by pressure, the radiating pains extending from below' upward even to 
the shoulder. The pulse in both is very small and frequent, and dys- 
1 Gazette des Hflp., 1875, p. 1065. 
2 Traite Clin, d Rheu. Artie., Paris, 1840. 12 
DONALDSON, DIAPHRAGMATIC PLEURISY. 
pnoea, hiccough, vomiting, dilatation of the stomach, icterus in cases of 
perihepatitis, all are sometimes present in peritonitis. 
In peritonitis, however, we must seek for those symptoms apparently 
the least prominent; the functional troubles of each viscus found in 
peritonitis, and, above all, we must look for the antecedent cause of in- 
flammation of the peritoneum, as cirrhosis, and cancer of the liver, or 
other organs. Thus, in a case given by Hermil,1 though the physical 
signs and symptoms were very misleading, the extreme dyspnoea, with 
absence of tumefaction on the right side, and of any swelling of the 
abdomen; and absence of vomiting and icteric taint; the consolidation 
of the bases of both lungs and the characteristic pains over the bouton 
diaphragmatique, settled the diagnosis of diaphragmatic inflammation. 
Furthermore, it would seem that whenever hiccough exists in peritonitis, 
it is always followed by vomiting (Charrier1). Peritonitis according to 
Foix3 and Hilton Fagge,4 is often complicated with diaphragmatic pleu- 
risy, and in such cases the diagnosis is very difficult. llervieux5 says 
that the absence of cough and expectoration, of lung consolidation, and 
auscultatory signs, is sufficient. Again, it is very difficult to distinguish 
an encysted supradiaphragmatic effusion from a subdiaphragmatic col- 
lection (Donaldson).6 
Complications and Terminations. — Diaphragmatic pleurisy is 
usually complicated with pneumonia, costo-pulmonary pleurisy, pericar- 
ditis, perihepatitis, and perisplenitic peritonitis. Williams7 says that peri- 
tonitis following diaphragmatic pleurisy is rare, though he gives a case 
of general peritonitis with inflammation of the under surface of the dia- 
phragm following this disease. Cailliete8 also gives two cases of fatal 
peritonitis produced by inflammation of the diaphragm. Petit,9 too, 
gives a case of perforation of the diaphragm, with fatal peritonitis, fol- 
lowing a diaphragmatic pleurisy. The termination in primitive cases is 
in cure, as will be seen later. In secondary cases it is usually fatal, 
about one-fourth only of such cases recovering. When an effusion forms, 
it is either absorbed or becomes purulent, and the patient either lingers 
a long time, or the collection becomes encysted. In the latter case, it 
either remains inert, producing no particular bad effects, and attract- 
ing no attention, to be found after death from other causes (Graux,10 
Boisseuil11); or it ulcerates through the diaphragm, causing death 
(Andral13). Or, again, it may be ejected through the lungs. Grisolle13 
gives a case where the pus of an encysted effusion was evacuated partly 
1 Loc. cit., p. 60. 2 Paris Thesis, 1855. 3 Paris Thesis, 1874. 
* Guy’s Hospital Reports, 1873. 6 Loc. cit. 
6 Pepper's System of Medicine, Art. Pleurisy, p. 563. 
7 Soc. Med. des Hop., 1873. 8 Paris Thesis, 1874. 
9 Bull, de la Soc. Anat. de Paris, 1866, xli. p. 497. 
10 Bull. d. 1. Soc. Med de Paris, 1874, p. 478. » Paris Thesis, 1876. 
12 Loc. cit., vol. ii. p. 405. 18 Path. Interne, vol. i. p. 438. 13 
through the lungs and partly through the lumbar region, and which 
resulted in cure. De Mussy1 also tells of two cases of cure after evacu- 
ation of the pus through a bronchus. 
Prognosis.—Briefly, in primitive pleurisy, the tendency is toward 
cure. In secondary cases the prognosis is always grave, especially where 
it occurs in those of tubercular diathesis, and in cases of great delirium, 
obstinate hiccough, and of bilious vomiting; of excessive dyspnoea and 
of a purulent effusion. Double diaphragmatic pleurisy is not, as a rule, 
of grave import. Inflammation of the left side of the diaphragm is of 
more serious import, owing to the occasional involvement of the peri- 
cardium. Pleurisy occurring in the course of puerperal fever is ex- 
tremely fatal. 
It only remains for us to speak of the so-called benign foir/t of dia- 
phragmatic pleurisy to which attention was first called by Bucquoy,2 and 
which would seem to be a distinct form of the disease. According to this 
writer, besides ordinary acute pleurisy, with more or less effusion, and 
that accompanying bronchitis or catarrhal pneumonia, with little or no 
effusion, and lasting a short time, there exists a separate and distinct 
form of acute benign diaphragmatic pleurisy, which always ends in cure. 
Hermil3 agrees with Bucquoy in this opinion, and says that he has seen 
a number of such cases. I find also that the articles on inflammation of 
the diaphragm published since 1879 treat exclusively of this somewhat 
peculiar and interesting form of acute benign pleurisy. Bouchut4 con- 
firms Bucquoy’s statements, and gives three cases of acute benign dia- 
phragmatic pleurisy, all ending in cure. Monod6 and Robert6 each re- 
port one case identical with the above; and Fiessinger7 nine cases, all 
ending in rapid and complete recovery. 
Acute benign diaphragmatic pleurisy begins, as does ordinary pleurisy, 
with chill, pain in the side, and fever. The painful points and radiating 
pains, the tender and retracted abdomen, etc., follow, and show con- 
clusively that the inflammation is of the diaphragmatic pleura. Up 
to the third day the inflammation is limited to one side only, but 
from the third to the sixth day it extends, and wre find the opposite 
side of the diaphragm involved. Its invasion of the other side is ac- 
companied, however, by no great pain, and indeed all the symptoms 
are much less than those of the side first affected. There is some slight 
consolidation of the lung bases with enfeebled respiration; there is but 
slight effusion and little displacement of the liver and spleen. While all 
the symptoms are much less pronounced on the side last affected, the 
DONALDSON, DIAPHRAGMATIC PLEURISY. 
1 Arch, de Med , July, 1879. 2 Clinique, etc., Paris, 1873. 
8 Loc. cit, p. 50. 4 Paris Med., June 17, 1880. 
5 Gaz. Heb. d Sc. Mod. de Bordeaux, 1880, i. p. 751. 
e Revista de Cirucias Medicas, Barcelona, 1881, xii. p. 3. 
7 Rev. Med. de Test., Nancy, 1885, xvii. p. 332. 14 
DONALDSON, DIAPHRAGMATIC PLEURISY. 
effusion on the side first involved rises to a much lower level than that 
of the opposite side. On the side first attacked we usually have a cer- 
tain amount of retraction of the base of the lung from the presence 
of the fluid between it and the diaphragm. This fluid, however, does 
not always occupy this place, but by reason of the retractility of the 
lung, which draws the fluid upward with it, the liquid is spread out, 
as it were, between the lung and the thoracic wall, and so we may have 
the physical signs of a large effusion, though, in fact, the amount 
actually thrown out is quite small. As a rule, in benign pleurisy the 
bilateral effusion disappears without surgical intervention, and the dys- 
pnoea, in spite of the double pleurisy, is but slight. 
Another interesting feature of this benign form of diaphragmatic 
pleurisy is that the last pleurisy developed is the first to disappear. 
Pending its duration, however, there is little or no progress of the 
disease on the side first attacked. The development of the second 
pleurisy would seem to arrest the first, and the tendency is toward 
rapid cure. There is, in general, but little systemic disturbance, and 
the fever is moderate in this form of the malady. The extension of 
the inflammation from one side to the other seems to lessen all the bad 
symptoms. All such cases result in cure in from two to four weeks 
(Monod,1 Hermil2). 
1 Du Ilermil, pages 73 to 77. 
2 Loc. cit , p. 66. THE MEDICAL NTWS. 
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