Acute Plastic Pleurisy.

Synonyms.—Dry Pleurisy; Fibrinous Pleurisy.

Etiology.—This form may be either primary or secondary. The former is where the inflammation occurs as an independent affection in a person previously healthy. It does not occur as frequently as was formerly diagnosed, many cases, no doubt, being due to a rheumatic or tuberculous constitution.

Although various micro-organisms are found in all forms of pleurisy, notably the bacillus of tuberculosis, the streptococcus pyogenes, the staphylococcus, and the micrococcus lanceolatus, no specific germ has been found as a causal agent. Associated with the above bacilli, have rarely been found the colon bacillus, the proteus vulgaris, Friedlander's bacillus, anthrax bacillus, influenza bacillus, and others.

The most common etiological factor is contracting cold, either by sudden atmospheric changes, or exposure in damp cold weather, or sudden cooling after severe exercise. Mechanical injuries occupy a prominent place as causal agents. The winter and spring months serve as an important factor in producing the disease, owing, no doubt, to sudden atmospheric changes. The disease occurs more frequently among men than women, owing to greater exposure of the former. The tubercular and rheumatic taint must also figure as having some bearing in these cases.

The second form is due to an extension, either acute or chronic, of inflammatory conditions of the lung or neighboring parts. Thus it frequently accompanies croupous pneumonia, and is often present in broncho-pneumonia, and is not a rare complication in hemorrhagic infarct, abscess, and gangrene of the lung, and cancerous conditions. It is nearly always present at some period in pulmonary tuberculosis, and in not a few cases is the first symptom of that dread disease.

It may also result from hepatitis, or cardiac inflammations.

Pathology.—Within twenty-four hours the inflamed membrane becomes reddened, congested, and deeply injected, showing many minute ecchymotic spots. The membrane, at first dry, loses its glossy appearance and becomes dull and lusterless, and soon is covered with a fibrinous exudate of a yellowish or reddish-gray color. When the exudate is profuse, it presents a shaggy appearance, due to the friction of the pleural surfaces. This exudate is composed of fibrin, leukocytes, blood corpuscles, and serum in small quantity.

While the inflammation is active and the exudate is profuse, adhesions of the pleura take place, owing to the presence in the exudate of embryonic round cells which develop blood-vessels and connective tissue. If the inflammation is of a mild character, the exudate undergoes fatty degeneration, and is absorbed.

Symptoms.—The symptoms of fibrinous pleurisy exhibit a wide range of symptoms. In one case a stitch in the side is the only reminder of the disease, while in another the pain is of an excruciating character and the prostration so great as to speedily terminate in death, and between these extremes are found every grade of symptoms.

When the disease is of the primary form, it is usually ushered in with a chill or chilly sensations followed by febrile reaction, though generally not of a very severe type, the temperature ranging from 101° to 103°, and in rare cases going to 104° or 105°.

The pulse is small and frequent, from 100 to 120. The secretions are all more or less arrested, the tongue being more or less coated, the skin dry, the urine scanty and high-colored, and the bowels constipated.

Of the local symptoms, the patient complains of a sharp, lancinating pain in the affected side, usually in the region, of the nipple. The pain is increased if the patient attempts to take a full inspiration, or if the affected side is moved. As a result, we find the breathing shallow or jerking, and principally abdominal. For the same reason the patient lies on the affected side, that the membrane may be held quiet.

A short, dry, hacking cough adds to the patient's suffering. With the appearance of the exudate the pain subsides, with an amelioration of all symptoms.

In some cases, the patient is seized with a hard chill, and, with febrile reaction, the temperature rapidly reaches 104° or 105°. The pulse is full and bounding; the face, at first flushed, soon becomes pinched and anxious. The pain is intense; the patient refraining from taking a full inspiration, has the appearance of great anxiety. The pulse soon changes, becoming feeble though rapid, prostration is extreme, and death may follow in forty-eight or seventy-two hours.

When the disease is secondary, the symptoms of the primary disease may so overshadow the affection of the pleura as to escape notice, though the stitch in the side, or an "uneasy" feeling, will call attention to the pleura, and a physical examination will reveal the true condition.

Physical Signs.—Inspection reveals the movement of the chest will, on the affected side, very much restricted, especially during the first forty-eight hours. Palpation confirms what inspection reveals, while percussion gives a normal sound in the early stage of the disease, to be followed by some dullness when exudation occurs. Auscultation reveals the characteristic and chief diagnostic symptoms of pleurisy.

In the early stage the friction sound is heard, due to the rubbing of the dry, inflamed pleural surfaces, and is more pronounced at the end of inspiration. With the presence of exudation, the friction sound is increased and is heard during expiration and inspiration. If deep breathing is enjoined, the sound is more pronounced.

Diagnosis.—If care is used, pleurisy can scarcely be mistaken for any other affection. The only diseases that might be mistaken for pleurisy are pleurodynia and intercostal rheumatism. If we remember, however, that the friction sound is always present in pleurisy, and never in the other two affections, we can readily distinguish the one from the other.

Prognosis.—The prognosis is usually favorable, though in rare cases it may speedily terminate fatally.

Treatment.—The earlier Eclectics obtained prompt results in the treatment of pleurisy, and those who can not get into the way of small doses and specific tinctures will find the old way a successful one. 'Tis true it is rather unpleasant, though, if the patient is suffering intensely, he is ready to submit to any medication that promises relief.

Where the tongue was full, pallid, and dirty, the old compound powder of lobelia or the acetous emetic tincture was given, at first in small doses to produce profound nausea, and then carried to free emesis. This produced relaxation, lowered the temperature, and eased the sharp, lancinating pain. If the pain was intense, sudorific tincture, compound tincture of Virginia snake-root, was given in teaspoonful doses, in hot water, every one, two, or three hours. This not only relieved the pain but brought on gentle perspiration, and the patient was soon convalescent.

In the place of this rather unpleasant medication, we give the small dose, and equally efficient remedies in the form of specific tinctures.

Aconite.—For the small, frequent pulse, aconite is the sedative to be selected, five gtts. of the tincture, to water four ounces.

Asclepias.—Associated, or rather combined, with the aconite; we will find asclepias an excellent remedy. Where the pain is severe and moves about, is not constant at one point, and the skin hot, either dry or moist, no better remedy can be given. From ten drops to one dram should be added to water four ounces; a tea-spoonful every hour.

Bryonia.—This is the remedy of remedies in respiratory lesion with chest pain. In pleurisy, the sharp, lancinating, stablike pains will call for bryonia. Ten drops to half a glass of water, and a teaspoonful every hour.

Rhus Tox.—Where the patient is restless, and unable to sleep, or starts suddenly in his sleep with a sharp stroke to the pulse, telling us of irritation of the cerebro-spinal centers; where the tongue is reddened at tip and edges and there is elevation of the papilla, the small dose of rhus will give good results. Ten drops, to water four ounces.

Veratrum.—In an extreme case there will be high temperature, the pulse will be full, strong, and bounding. The face will be flushed, there will be throbbing of the carotids, and the pain is intense, agonizing in character. In such a case veratrum, 1 drachm; morph. ½ grain, to water four ounces; a teaspoonful every hour until the pulse feels the force of the remedy, when it should be given every two or three hours.

Local Measures.—In most cases, libradol will afford relief, and is more satisfactory than a blister. In fact, the day for the application, of blisters in pleurisy has gone by, and when an active counter-irritant is demanded, the application of chloroform to the spot implicated will give relief.

A hypodermic of morphia may be called for, where the pain is intense in character and we can not wait for the slow effects of internal medication. Pain sometimes kills or at least hastens a fatal termination, and the strength of the patient may be greatly prolonged by the timely use of a hypodermic injection. It is only to be used, however, in cases like the one just named. Should the pain return in four, five, or six hours, a diaphoretic powder, administered before the pain becomes intense, will be of much benefit.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.