Acute Pleurisy.

Synonyms:—Acute plastic pleurisy; dry pleurisy; dry fibrinous pleurisy.

Etiology:—It is seldom that pleurisy occurs, as an idiopathic disease, in a patient previously of good health, presenting no premonitory symptoms. This, however, is the typical presentation of acute pleurisy. It occurs from exposure to extreme cold or to a sudden change from warm weather to a cold and very damp spell. It occurs also as the result of a direct blow upon the chest walls or other mechanical injury.

The condition may occur secondarily to other acute diseases of the lungs, bronchial tubes or other contiguous organs. It is dependent also upon acute rheumatism, upon various neuroses and it accompanies pulmonary tuberculosis.

In this form of the disease there is not that copious effusion that is present where there is purulency, but as a result of the engorgement of the pleural membrane there is a diffused but slight fibrinous exudate. This induces a roughness of the serous surface, which is the immediate cause of the acute pain, as it interferes with the normal movement between the parietal and visceral surfaces of the pleura, unless the disease is prolonged and severe, there is no great quantity of exudate and firm adhesion does not take place.

Symptomatology:—The disease is inaugurated with the occurrence almost simultaneously, of a chill, a severe, sharp, cutting, lancinating pain in the side, an abrupt rise in the temperature, and usually a severe cough which greatly aggravates the pain. There are but few, if any, premonitory symptoms. The pain is intermittent in character at first, occurring only on inspiration or upon movement. The patient is inclined to hold the affected side with the hand and lean toward that side to prevent movement and muscular tension. The respiration is short, irregular or broken, cut short by the pain. There is a dry cough, which is restrained with every possible effort, because it increases pain. The face is pale and anxious, and the patient soon shows signs of severe illness. The pulse is small, hard and quite rapid; from one hundred to one hundred and twenty-five. The temperature in a typical case will not usually exceed 102.5° F.

While these symptoms are those of an average case of acute pleurisy the symptoms will vary from those so mild in character as not to interfere with the patient's work, receiving but little attention, to an extreme manifestation with severe chill, high temperature, unbearable pain and rapid prostration.

Diagnosis:—The sudden occurrence of the acute pain, which interferes so materially with the inspiration, is the important diagnostic factor in this condition. The restriction of the affected side, in motion or in breathing, some dulness on percussion, the friction sounds or fine rales that are present on auscultation, will all distinguish this disease from intercostal neuralgia, as well as the chill and fever, which are not present in neuralgia.

In muscular rheumatism the pain and soreness are in the muscles alone and are not influenced to so great an extent hy the respiration. The condition is distinguished from pneumonia by the progressive development of the latter disease, by the character of the cough and expectoration, by the chest signs and by the severity of the constitutional symptoms in pneumonia.

Prognosis:—When this condition occurs in an uncomplicated form it is not by any means a dangerous one, as nearly all cases recover. It lasts from three to twenty days. But a severe attack renders the patient liable to subsequent attacks. And if the condition is not at once aborted, the results of the inflammatory action, such as thickening, roughness of the serous surfaces or adhesions, may occur and may become more or less permanent and thus interfere to a material extent with normal chest expansion and the oxidation of the blood.

Treatment:—The patient should be put immediately to bed and absolute quiet enjoined. A mustard plaster should be prepared from freshly ground mustard mixed with warm water, to form a thin paste. A little of the white of an egg may be added to prevent blistering, but if the poultice be carefully watched blistering will not occur. The mixture should be spread over a piece of thin cloth sufficiently large to cover the entire affected side. This should be laid upon a hot plate, carried to the bedside and transferred directly to the painful area, covering the larger portion of the affected side. This should be kept very warm from four to eight minutes, occasionally turning down a corner of the poultice to observe the redness of the skin. When the skin is thoroughly reddened the poultice should be removed and an application made of sweet oil or vaseline, the chest very warmly covered and the painful area kept hot with a rubber water bag or hot water bottles.

If the mustard poultice be large enough and of good strength the pain is entirely relieved for the time being. Later, if the pain returns, the chest walls may be strapped much after the manner adopted in the treatment of a fractured rib, passing the straps horizontally around the body across the ribs from the spine to the breast bone, each overlapping the other. However, if strapping is not done and the pain returns, another sharp mustard poultice may be applied for a few minutes from twelve to eighteen hours later, if the surface was not previously blistered.

Our most specific remedies in pleurisy are bryonia, asclepias and aconite. Bryonia seems to have a specific selective action for the pleural membrane. When given immediately at the onset it inhibits the outpour of an exudation, overcomes the local congestion, relieves the pain, controls the fever and terminates the condition within a very few days, leaving no apparent results of the acute inflammatory action and to a limited extent fortifying the patient against subsequent attacks. At the onset of the attack the indications for aconite are present—the dry, hot skin, sharp, hard, quick, rapid pulse, with restlessness—the two remedies may be given in conjunction or alternately; by so doing a more immediate result will be obtained. From three to five drops of specific aconite in four ounces of water and from ten to fifteen drops of specific bryonia in four ounces of water should be given in teaspoonful doses every half hour or hour. If there be no inclination to the return of the pain, bryonia alone will be sufficient. Those physicians who are not familiar with the comprehensive action of bryonia use aconite and asclepias tuberosa. From five to ten drops of the specific asclepias may be given every hour until the skin is moist and the symptoms abate, when it may be given every two or three hours. Any practitioner who uses these remedies with confidence will not return to the action of opium in pleurisy, as this course is in every way superior. There is, however, an exceptional case, occasionally, in which the pain and soreness and consequent impediment to the respiration will continue and persist. In this case, if opium be used at all, one, two or three doses of five grains of the diaphoretic powder or of Dover's powder may be given, or half of a dram of the deodorized tincture of opium may be added to two ounces of water and a teaspoonful of this may be given every hour, for a few doses, when there will be some relief from the pain and the remedy may be gradually withdrawn, dependence being placed upon the specific remedy. The influence of opiates in large doses is in line with the underlying pathological elements involved in the development of the disease, and the remedy should be avoided entirely if possible.

Acute pleurisy occurs sometimes with slight elevation of the temperature only, but with pronounced chill, cold extremities and moist, cool skin, the patient being dull or somewhat apathetic and indifferent. In such a case belladonna must be administered in sufficient dosage to exercise its physiological influence within the course of from four to six hours, this will antagonize the congestive tendency of the disease and will greatly promote the ultimate cure. It may be continued in smaller doses for perhaps forty-eight hours if no contraindications present.

When with a sharp onset of the disease there is considerable nervous excitability, with restlessness, dry, hot skin, bright eyes with contracted pupils, and continued motion, gelsemium will accomplish very satisfactory results. It may be given instead of aconite and alternated with bryonia. During convalescence the patient must avoid exposure and the breathing of cold air and must keep the chest well protected.

The Eclectic Practice of Medicine with especial reference to The Treatment of Disease, 1910, was written by Finley Ellingwood, M.D.