Sub-acute Pleurisy.

Synonyms:—Pleurisy with effusion; sero-fibrinous pleurisy.

Etiology:—This form of pleurisy is usually secondary to other inflammatory conditions. When resulting from cold it is induced by prolonged exposure and dampness or by working in the water or in wet clothes in the cold. It may also follow an injury to the chest wall, developing somewhat slowly, not appearing until several days after the injury. It is not an uncommon sequel to acute articular rheumatism and will also occur during the course of the infectious diseases, of pericarditis or of pneumonia. It is a most common complication of pulmonary consumption, being readily induced in those of a tubercular diathesis.

Symptomatology:—The disease may occur as a primary condition idiopathically, but it develops more slowly than the dry form with premonitory symptoms. In other cases a pain in the pleura may have been present for a number of weeks, slowly increasing in severity, restricting the breathing, but not sufficiently severe to attract the attention of the physician. It may have been taken for rheumatism or neuralgia, or may be thought to be the result of a local injury. Thus insidious in its development, the disease is fully developed before a careful examination reveals its actual character.

There is but little fever in this form. It is scarcely perceptible in the day time, but increases in the early evening to perhaps 101.5° F. and continues during the night. The pulse is soft and compressible during the day, but increased in rapidity, is hard and perhaps wiry during the increase of the temperature. Cough is apt to occur early before the character of the condition is discovered. The patient will remark, as with movement and deep breathing, that there is invariably a sharp increase of the local pain upon every effort of coughing. From the first he loses strength and becomes emaciated. The face is pale and anxious, there is anorexia, constipation, insomnia and increasing lassitude and indisposition. As the effusion develops the patient leans toward the affected side; when walking, may continue to press his hand against that side, and will invariably lie on that side when sleeping.

Upon inspection the physician will observe the position of the patient, the decrease of movement on the affected side upon breathing, and the increase of respiratory action on the unaffected side. Later there will be a distention of the spaces between the ribs, and increased dulness or flatness on percussion over the affected area; the area of dulness may be changed by changing the position of the patient, unless, as may be the case later in the disease, the effusion be circumscribed by adhesions.

With the full development of the disease the breathing is embarrassed, always painful, especially the inspiration, which is often cut short by the pain, as in the acute form. The breathing is rapid and shallow, materially interfering with proper oxygenation of the blood. Where the effusion develops rapidly, until there is a large quantity, so great is the obstruction to the breathing that cyanosis may develop. With this condition the patient becomes very restless, the respiration is rapid and shallow, the pulse is small, feeble, exceedingly rapid and easily compressible, the skin will become cool, and in exaggerated cases death seems imminent.

Subacute pleurisy may last from two to four weeks, or it may become chronic in character. Usually after perhaps twenty-one days the temperature declines to the normal point, the pain is diminished and there are evidences of the absorption of the effusion. These evidences are a reduction in the size of the chest walls, a gradual restoration of the respiratory movement and a decrease in the bulging in the intercostal spaces. As convalescence progresses an apparent reduction in the size of the affected area to less than normal is apparent, and as the patient walks, it will be found that he leans naturally toward the diseased side, carrying the shoulder and the arm a little lower than usual. This, however, may not be a permanent deformity. It will be overcome as the normal condition of the chest is obtained and upon the return of vigorous health.

While we have narrated the facts concerning a slow or gradual development of the pleuritic effusion it is not uncommon to find evidences of a mild exudation only, which may be present for some days, when, with considerable rapidity, the pleural cavity becomes filled to distention with the effusion, with a correspondingly sudden development of all of the concomitant symptoms. With this the disease assumes a severe and dangerous type, and unless the effusion is removed by surgical means, death may occur suddenly.

Diagnosis:—While it is not difficult usually to determine the presence of a fluid in the pleural cavity, there are cases in which a positive diagnosis of this disease is not readily made. It is necessary also to determine at once concerning an effusion, whether it be serous, purulent or sero-purulent. The dulness present must be distinguished from hepatization of the lung, from interstitial inflammation, as in pneumonia, from the various forms of pulmonary congestion, and from the dulness of tubercular conditions. The character of the development of the disease, a history of the previous existence of some condition that could induce it, the presence of the characteristic pain of pleurisy, which is permanent in its location, with the character of the breathing and the subsequent evidences of a slowly increasing effusion, point unmistakably to the presence of this form of the disease.

Prognosis:—The prognosis as to a total ultimate recovery is fairly good. There is a tendency, as has been stated, for the condition to become chronic, and if this occurs, changes take place which are not readily relieved by any measures. A sudden and rapid increase of the effusion is an alarming symptom and greatly increases the danger. If the underlying cause is incurable in character, as when the disease follows Bright's disease, syphilis and tuberculosis, but little, of course, will be accomplished in the treatment of the pleuritis.

Treatment:—The indications for specific treatment at the onset of this condition are somewhat similar to those of a dry form of the disease. The pain will suggest the necessity for the use of asclepias tuberosa. which the author has given in fifteen-minim doses every two hours with excellent results. This will increase the secretions of the skin materially and will facilitate the normal respiratory function, encouraging constant oxygenation. Later, as fever develops, the indications for bryonia will appear distinctly. This remedy should be given for its influence in retarding effusion until the pain has materially abated and the cough has decreased. To promote absorption of the fluid we have several remedies of value. If there be indications that rheumatism may be present within the system in any form, or that a rheumatic diathesis exists, the salicylate of sodium in from five to ten grain doses may be even every two hours for several days.

If there are evidences of exhaustion, with nervous weakness or feebleness of the heart's action, especially if any actual disease of the heart may be present, with feebleness, apocynum will exercise an actively restraining influence upon the increase of the exudation and will ultimately assist in its removal. The use of small doses of the sulphate of magnesium, as perhaps twenty grains every three or four hours, will be beneficial also.

The depleting measures advised by the faculty have been proven by the experience of eclectic physicians not only to be greatly inferior to the persistent action of correctly adjusted remedies, but to be positively harmful and often productive of serious results. When distention of the chest is conspicuous, the character of the fluid should be examined. This may be done by the use of an ordinary hypodermic syringe having a needle of sufficiently large caliber to permit the passage of small masses of pus cells or coagulated fibrin, in case these be present. If serous in character a portion only of the liquid should be drawn through an aspirator, the needle being introduced between the fifth and sixth or between the sixth and seventh ribs, corresponding with the locality of the fluid, a low dependent portion being selected. It is not necessary that the entire cavity be evacuated when serum alone is present; in fact, there are some objections that may be imposed against its complete evacuation. Absorption of the remaining fluid may take place with facility, after pressure is in part withdrawn from the lungs, and from the circulation in the blood vessels and lymphatics. We do not advise the withdrawal of any quantity of the serous fluid when but a small quantity is present. It is only when it acts as an impediment to the respiration or circulation that it need be reduced in quantity. Pus, of course, demands immediate removal and thorough irrigation of the cavity from which it was withdrawn.

The general condition of the patient must have constant and careful attention, the nervous system must be sustained by well selected tonics, the condition of the digestion and food appropriation must be constantly watched and the patient nourished to the fullest extent. The use of alteratives is beneficial, as the blood is apt to become quickly impaired, the red corpuscles diminishing and the white corpuscles increasing in number. When the fever has disappeared or is declining an excellent tonic is the quinin bisulphate in two-grain doses every three hours. It seems to have a special selective influence in its tonic operations upon the respiratory organs, antagonizing pathological conditions of whatever form and restoring normal functional action. The salt is in every way preferable to the sulphate. If with the pleuritic involvement there be much cough, with bronchial irritation or actual consolidation of lung structure, the dose named should be given with one-fourth of a grain of powdered ipecac every two of three hours. To this may be added one grain of the precipitated carbonate of iron if there is apparent anemia, or if it seems necessary to increase the red blood corpuscles to promote a more perfect oxygenation. If the general nutrition is impaired, with enfeeblement of the stomach and appropriative organs, nux vomica and hydrastis canadensis are demanded. These remedies are of essential importance in general restoration and in the upbuilding of the patient and will usually cover the larger portion of the indications for treatment. Some authors lay great stress upon iodin in the final restoration of these cases. The agent will be of much advantage in an occasional case, but it should not be looked upon as one of wide influence. It may be given as the potassium iodid or in small doses of the compound tincture of iodin, or the syrup of the iodid of iron may be administered. The recently prepared iodo-neucleoid is a most serviceable form, constituting as it does an organic iodin.

The surroundings of the patient must receive attention. The patient should be removed to a warm climate if the condition has been very severe, and should have persistent but correctly adjusted out-of-door exercise. The food should be of a concentrated and highly nutritious character and its immediate appropriation should be encouraged either by partial predigestion or by the use of artificial digestives. The patient should be taught to increase the respiratory power by the exercise of the lungs, in regular deep breathing or by the practice of a regular system of respiratory gymnastics, not too severe in character.

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