Chapter 7 - Diseases of the Chest
Consumption - First Stage
Consumption - Second Stage
Consumption - Third Stage
Causes of Consumption
Bacterial Invasion
Classes of Bacteria
Exciting Causes of Consumption
Treatment of Consumption
Diet in Consurnption
Acute Bronchitis
Chronic Bronchitis
Swelling of the Lungs
Pulmonary Apoplexy
Air in the Chest
Water in the Chest
Lungs and Their Diseases - Diagram
Charts of Various Lung Diseases - Diagram
Typhoid Pneumonia
Broncho Pneumonia
Other Forms of Lung Inflammation
Hay Fever
Thyroid Gland

7.18 Pleurisy

Pleurisy. Pleuritis.

Pleurisy, or pleurisy fever, as it is sometimes called, is an inflammation of the pleura, or the membrane which lines the chest, and, at the same time, is folded back so as to cover the outer surface of the lungs.
The pleura, as is elsewhere explained, is a short sac or bag, whose inner sides are kept moist, so that they may slide easily upon each other as they are moved by the alternate contractions and expansions of the lungs in the act of breathing, and whose outer sides are made to grow, one to the inside of the chest, and t be other to the outside of the lungs.
Pleurisy and lung fever, then, must be kindred diseases, and exist, more or less, together. In truth there is almost always some affection of the pleura in lung fever, and some affection of the lungs in pleurisy. The pain in lung fever is owing to some inflammation of the pleura; and the appearance of the rust colored phlegm in pleurisy indicates that the lungs have been reached by the inflammation of the membrane which covers them.

Physical Signs. Flatness on percussion, at the lower part of the chest, which ascends as the effusion of water increases.
If the effused fluid is not great, there is puerile breathing at the top of the lung.
Friction sound is heard occasionally in first stage of disease.
Egophony is heard when the amount of fluid in the pleura is small.
As the amount of water increases, bronchophony appears.

General Symptoms. This disease is most frequently introduced by shiverings, which are soon succeeded by high fever, with a peculiarly hard, resisting pulse; sharp, stabbing pain in the side, generally just below the nipple, but sometimes extending to the shoulder, arm pit, and back; hurried and interrupted breathing; and a short, dry cough.
The pain is greatly aggravated by motion, coughing, or an attempt to take a long breath. It holds the patient under constant and powerful restraint. We find him lying upon his back, or his well side; his countenance full of anxiety, fearing to move, cough, or even breathe needlessly; and often crying out from the keen torture these necessary acts inflict in spite of all his caution.
At a more advanced stage, when the tenderness has somewhat abated, he will prefer to lie on the diseased side, as this leaves the healthy lung more at liberty.

Observations. The first effect of the inflammation of the pleura is to dry up the moisture with which its inner surfaces are lubricated, or made smooth and slippery. As a consequence, these surfaces become rough, and rub harshly upon each other, and produce a sound, in the early stages of pleurisy, like that of rubbing two pieces of wet leather together. It may be imitated by rubbing the finger back and forth upon a table. It is sometimes a creaking noise, like that of new shoes.
As the disease advances an important change takes place in the state of things. Instead of an unnatural dryness, a watery fluid is poured out copiously from the inflamed surfaces of the pleural sac. This is called the period of effusion. This generally, though not always, relieves the pain. But, by compressing the lung, causes dangerous difficulty of breathing.
The air cells are compressed by the effused fluid, and are not penetrated by air. Hence the absence of the breathing murmur.
The pouring out of water between the layers of the pleura, compresses the lung, and remove ' s it from the walls of the chest. Hence the dullness or deadness of sound upon percussion.
When listening with the stethoscope, the voice of the patient sounds feeble and interrupted, like the bleating of a goat, and is hence termed, egophony, or goat voice.
This peculiar voice is beard only when the effusion of water has been moderate in quantity, and only a thin layer of liquid lies between the ribs and lung. It is caused by the voice passing over this thin layer, which is thereby thrown into vibrations, or wavy, quivering motions. When thus agitated, the fluid reacts upon the voice, making it sharp and tremulous.
When the effusion has become large, these effects cease; but another sign then shows itself, and distinguishes pleurisy from the healthy state, and likewise from the solid, hepatized state of the lung in lung fever. It may be discovered thus:
If the hand be laid flat upon the chest of a healthy person, while he is speaking, a vibration or thrill will be left. If, in like manner, the hand be laid upon the chest of a person having lung fever, with hepatized lung, this thrill will be found still more perceptible. But when the band is placed over the place of watery effusion on the chest of a person having pleurisy, there will be discovered, when the person speaks, no thrill whatever. The absence of this thrill, then, is one of the very best signs of pleurisy with effusion.
Persons recover from pleurisy sometimes very rapidly, before effusion has taken place. It is then said they have had an attack of dry pleurisy. When liquid has been poured out, even in considerable quantity, it is sometimes reabsorbed, and the patient recovers perfectly. In other instances, it compresses the lungs, interferes seriously with breathing, reduces his strength, and he sinks rapidly.

Treatment. Pleurisy has been divided for description and treatment into three stages, following the natural events of the inflammation. The first stage comprises the period from the first onset to the time when effusion commences. The second stage, or stage of effusion, extends to the time when the liquid begins to diminish; and the third stage consists of the period occupied by the absorption of the liquid.
Should the quantity remain stationary or diminish very slowly after the lapse of two or three weeks, the disease becomes chronic.
The indication for treatment during the first stage is to arrest the progress of the disease, to diminish its intensity, to limit the amount of morbid products, and to relieve suffering.
If the patient is full blooded and has a hard, frequent pulse, accompanied with extreme pain and fever, tincture of veratrum viride in 5 drop doses, or tincture aconite in 2 drop doses, should be frequently repeated. If the patient is weak and exhausted give tincture digitalis in 5 drop doses the same way. If effusion has not already begun a strip of lead plaster twelve inches wide and long enough to extend around the. chest from the breast to the back bones, should be tightly stretched over the ribs on the affected side. Hot turpentine fomentations frequently changed, or (130) will do much towards alleviating the pain. If the effusion has begun give a mixture of the acetate of potash 30 grains and infusion digitalis two teaspoonfuls every 3 or 4 hours.
It is well to administer salicylate of soda in 10 grain doses every three hours till a little ringing is heard in the ears, then once in four hours. This drug increases the action of the skin and kidneys and overcomes the rheumatic element present in most if not all pleurisies. The diet should be dry, all liquids being excluded, that the abstraction of water from the chest may be favored.
Nothing gives so much and such immediate relief to pain as a subcutaneous injection of morphine. Aconite also is a valuable sedative in this stage. It may be given in half or whole drop doses every fifteen minutes for two hours; then afterwards a drop, to be repeated hourly till some impression is made upon the heart's action. Smaller doses are to be given if the pulse becomes feeble.
In the second stage, if the acute symptoms have yielded to treatment, as they usually do, the object of treatment is to promote the absorption of the fluid. This is done by the judicious use of saline cathartics and by diuretics, for the bowels and the kidneys are the natural pumps of the system.
The application of counter irritants is also of use for this purpose, such as the tincture of iodine. If at any time during this stage the effusion is rapid and excessive, so as to endanger life, it is to be drawn off by puncturing the chest between the fifth and sixth ribs on the side with a small trocar, and the fluid is to be drawn off by suction.
Convalescence commences when the liquid begins to be absorbed; and active medication should then cease, and that course should be pursued which will lead to the restoration of the general health. This is done by tonics, a nutritious diet, and other hygienic means. If the effusion ceases to be absorbed or the process takes place very slowly, then that state of things exists which is called chronic pleurisy. Then the main objects of treatment are to effect the removal of the fluid, and to develop and sustain the powers of the system. Under these circumstances, it is better to discontinue remedies which act upon the bowels and kidneys, at least for a time, and try general treatment. This consists of tonics, stimulants, and general exercise m the open air, and with this the surgical removal of the fluids from the cavity of the chest.
The operation is now so much improved, and is so safe and simple and attended with so little pain, that it has become an every &y practice, and an operation which was only resorted to as an extreme measure to save life, is now admissible whenever the pleural cavity remains filled with liquid after only a brief trial of the remedies assigned to promote absorption.

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