Definition.—A chronic inflammation of the pleural membrane, with or without effusion.
Etiology.—Chronic pleurisy with effusion may follow an attack of acute sero-fibrinous pleurisy, or it may come on insidiously, or follow empyemia; in either case, the causes, conditions, and symptoms are largely the same as those already considered, and need no repetition.
Chronic pleurisy may follow pleurisy with effusion, where the fluid has either been absorbed or withdrawn, in which case there is retraction of the affected side. Not infrequently it comes on insidiously, being chronic from the onset, or it may follow acute plastic pleurisy; pneumonia is not infrequently followed by this form of pleurisy.
Pathology.—Where the pleurisy has followed a sero-fibrinous effusion or pyemia, the pleural surfaces are frequently left covered with a fibrinous exudate, which undergoes organization, the surfaces becoming adherent. In some cases there are prolongations from this new connective tissue, which extend into the interlobular septa of the lung. These extensive tissue changes prevent a free expansion of the lung, which ultimately may result in fibroid phthisis. Cysts containing a serous fluid or inspissated pus, in which lime salts have been deposited, are sometimes found in the adherent pleural walls.
Where the pleurisy is primary, the membranes become adherent from the fibrinous exudate; but the connective tissue is more apt to be confined to the pleural surfaces, the lung being left free.
When secondary to tuberculosis, small tubercle masses may be found in the walls of the pleura. In some cases there is thickening of the adherent pleura, restricting the free expansion of the lung, and where effusion has proceeded, the dry form restriction and deformity exists.
Symptoms.—Chronic pleurisy manifests itself by occasional sharp, lancinating pains through the affected part, especially after exertion, much talking, coughing, etc. We call the pain sharp and lancinating, but it may be more properly described as an intense, sharp soreness, which catches the part during inspiration, and stops the movement at once; the patient calls it a "stitch in the side." In addition there is frequently soreness on pressure, or when the arm of that side is moved. Respiration is more frequent than usual and somewhat difficult; there is more or less of a hacking cough, sometimes dry, but very frequently attended with expectoration, sometimes copious.
The general health is markedly affected; there is a loss of flesh and strength, the appetite is poor, the bowels are irregular, the skin is harsh and dry, the pulse 96 to 100, and there is much irritability of the nervous system. Usually there is hectic fever in the evening and night-sweats, sometimes as marked as in phthisis.
Physical Signs.—Inspection shows more or less deformity on the affected side. The chest is flat, retracted, with slight curvature and dropping of the shoulder. Compensatory expansion is noted of the opposite chest. The apex beat is feeble, or may be entirely absent, where overlapped by an emphysematous lung or when displaced behind the sternum.
Percussion reveals more or less dullness, depending upon the amount of thickening and compression of the lung.
Auscultation reveals a feeble respiratory murmur, and a cracking friction sound.
Diagnosis.—The history, together with the dyspnea, cough, pain in side, and by noting the physical signs already mentioned, the diagnosis is readily made.
Prognosis.—The prognosis will depend upon the previous history of the patient, length of time affected, the cause, and the general condition of health.
Treatment.—As much, if not more, depends upon improving the general health, as in treating the patient for the local lesion. If we can succeed in giving the patient a good appetite, in aiding digestion, in establishing secretion from the skin, kidneys, and bowels, and in controlling the circulation and innervation, we will have but little difficulty in checking the cough, relieving the pain, promoting absorption, and establishing a cure.
To accomplish the first, the patient must be much in the open sunshine, and, where possible, advise a change of climate, to one where there is a maximum of sunshine, equable temperature, and medium altitude; this, with a good bitter tonic, like nux and hydrastine phosphate, will do much in accomplishing the first part of the cure.
As the appetite is sharpened and digestion improved, there will be better assimilation and blood-making. Proper baths and the saline diuretics, the acetate, citrate or nitrate of potassium, largely diluted, improve the condition of the skin, kidney, and bowels, and promote absorption if effusion be present.
In the way of local treatment, nothing will give better results than the old compound tar-plaster, used until it promotes suppuration. If much effusion be present, the pleural cavity should be drained.
For the cough and pain, bryonia and asclepias are favorite remedies, though lobelia, sanguinaria, ipecac, sticta, and like remedies, will often be indicated. The antiseptics will sometimes be found useful, and echinacea, the mineral acids, the chlorates, and sulphites will give good results.