Synonyms.—Subacute Pleurisy; Pleurisy with Effusion.
Etiology.—The causes of sero-fibrinous pleurisy do not differ from those of plastic pleurisy, the difference in the character of the exudate being, no doubt, due to different degrees of intensity in the inflammatory process or to the influence of the various lesions with which it is so frequently associated, such as croupous and broncho pneumonia, pericarditis, hepatitis, peritonitis, nephritis, typhoid fever, carcinomatous conditions, and especially tuberculosis. The frequency with which tuberculosis is preceded by pleurisy or pleuritic symptoms being proof that the blood is of a poor quality, hence the changed character of the exudate. This is especially so where the exudate is purulent or hemorrhagic.
Pathology.—Sero-fibrinous pleurisy may be the further development of the plastic variety, the serous exudate following later, or the exudation may be serous from the beginning. The pleural surfaces are covered with a fibrinous exudate, varying greatly in character. In one, it is in the form of a thin, smooth coating, while in another it will be thicker, and assume a rough or shaggy appearance owing to the friction of its surfaces.
If there be no adhesions, the effusion collects in the most dependent portion of the pleura, and, if small in quantity, physical signs will be absent. The amount varies from a few ounces to a gallon or more. The fluid is usually clear, of a pale yellow or brown-green color, though sometimes turbid, of alkaline reaction, and contains red and white corpuscles, leukocytes, endothelial cells, threads of fibrin, albumen, and sometimes crystals of cholesterin.
As the fluid increases in quantity, certain mechanical changes take place. At first the lung is but slightly retracted; but as the fluid accumulates, the lung is crowded backwards, and from continued pressure becomes almost bloodless and airless—atelectatic. The mediastinum is drawn toward the opposite side by traction of the sound lung. The heart also is slightly displaced. Where the effusion is in the right side, the diaphragm is pressed, crowding the liver downward, while the stomach, colon, and spleen suffer in the same way, if the exudate be in the left pleura.
Symptoms.—Acute sero-fibrinous pleurisy begins insidiously. There may be slight chilly sensations for one or more days, followed by more or less fever, the temperature ranging from 101° in the morning to 103° at night. The pulse is generally small, but frequent, from 100 to 120 per minute. The urine is scanty, partly due to the fever, and partly to diminished arterial pressure.
In rare cases, the invasion is characterized by a severe chill, followed by high temperature, marked arrest of the secretions, sharp pain of a tearing or lancinating character, and marked dyspnea and an irritating cough. The pain is located-beneath the nipple, and is often referred to as a stitch in the side, though, in some cases, it is diffused and affects the entire side of the chest. In rare cases, diaphragmatic pleurisy, the pain may be in the epigastric, hypochondriac, or lumbar region.
If the effusion has been very slow in forming, there may be but little dyspnea, although the accumulation be large; generally, however, dyspnea is a characteristic symptom, the breathing being short and catching, and, where the effusion is rapidly formed, the dyspnea is so great that the patient is often unable to lie down.
Cough is an attendant symptom, beginning in the early stage, gradually declining as the exudate increases, again to return with absorption of the fluid. The cough is hacking in character, and attended with an expectoration of scanty mucus, which is not unfrequently streaked with blood. If bronchitis develops, the expectoration becomes quite profuse, and if pneumonia attends, the sputum is rusty colored.
In rare cases, where the primary disease is of a malignant character, or some severe chronic disease, as nephritis, the pleural symptoms may be absent, or so overshadowed as to remain unnoticed until discovered by a physical examination.
Physical Signs.—Since the general symptoms of sero-fibrinous pleurisy are often obscured by the primary disease, it is therefore important to carefully note the more definite and positive physical signs, which quite accurately determine the stage and extent of the lesion.
Inspection.—Inspection reveals the same conditions that we find in dry or plastic pleurisy; namely, increased frequency of respiratory movement; but as the exudate accumulates, restriction of the respiratory movement can be noted, due to the gradual compression of the lung, and when a very large quantity of fluid is present, the respiratory movement may be entirely absent. There will also be a bulging of the middle and lower part of the chest, the intercostal spaces being effaced and the anteroposterior diameter of the chest being increased. The diaphragm is depressed and the shoulder elevated, the affected side being perceptibly larger than its opposite fellow.
If the left chest be involved, the apex beat will be seen to the right of the median line, in the third and fourth interspace; and if the right chest be involved, the impulse will be seen to the left of the nipple, or even to the axillary line in the fourth and fifth interspace. This is quite noticeable if the patient be lean, with thin chest-walls.
Where there is resorption, we notice a gradual return to the normal condition, provided the exudate does not become organized, and adhesion takes place. In such cases there is atrophy of the affected side, which may result in marked deformity, there being retraction with a narrowing of the intercostal spaces, and a dropping of the shoulder, producing, more or less, a curvature, the concavity being on the affected side.
Palpation confirms the physical signs revealed by inspection. Thus the expansion movement is found to be much restricted, the interspaces widened and effaced, apical beat displaced to the right or left, ascending to the side affected. Fluctuation and edema are rarely found. Vocal fremitus diminishes as the fluid accumulates, and finally may disappear entirely. As resorption takes place, palpation reveals the progressive steps towards recovery, and where deformity of the chest occurs, palpation outlines the extent of the tissue changes.
Mensuration.—In measuring the affected side, we are to remember that, in right-handed adults, the right chest is the larger; hence the measurement must be as to the expansion of the two sides, the affected side showing one or two inches in excess at the end of expiration. Where there is great effusion, the affected side, of course, also shows an excess in measurement. There will be but slight difference between the sides during inspiration owing to expansion of the sound lung, while the affected lung remains airless.
Percussion.—Early in the disease, percussion gives negative results; but as soon as the fluid amounts to one pint, dullness is elicited, at first posteriorly, and in .rare cases, in the infra-axillary region, the amount of effusion can be determined from time to time by the increased dullness. The dullness beginning immediately below the line of fluid, the sound soon becomes flat, like that produced from percussing wood; hence the term wooden.
Beginning at the base posteriorly, the fluid, as it fills the cavity, assumes the form of the letter S, being higher posteriorly. Except in extreme cases, a point of resonance, tympanitic in character, is found just beneath the clavicle, and is known as "Skoda's" resonance. Where there is large accumulation of fluid, the dullness extends quite a distance below the diaphragm, owing to the depression of the viscera—the liver on the right, and the spleen on the left—and should not be confused in the mind of the operator. Unless a very large amount of fluid be present, change of position will vary the dullness and help determine the extent of the exudate. In percussion we are also to bear in mind the slight change in the heart position.
Auscultation.—In the early stage, the breathing is shallow and jerking, owing to pain, and the natural respiratory murmur is diminished; very soon, however, crepitation is heard, either in the inframammary, the infra-axillary or the infrascapular region, and while it may be heard both during inspiration and expiration, it is more pronounced at the end of inspiration. It may be dry and creaking as of new leather, or it may simulate pneumonia. As the fluid accumulates, the crepitant and respiratory sounds become fainter, finally disappearing, to be replaced by bronchial breathing.
While vocal resonance is greatly diminished or absent over the effused material, it often partakes of a nasal character near the border of the fluid, and resembles, somewhat, the bleating of a goat; hence is termed egophony.
With resorption, we have these adventitious sounds reversed as the fluid disappears, though a return to the normal respiratory murmur is often delayed for many weeks.
SPECIAL CLINICAL FORMS OF ACUTE SERO-FIBRINOUS PLEURISY.—Tuberculous Pleurisy.—This form does not differ materially from that just considered, save the additional presence of the specific tubercle and the more certain termination in death. This form is nearly always secondary to pulmonary tuberculosis, and is preceded by such a history. In rare cases, the primary lesion may be located in the pleura and consist of but few areas of tubercles, or there may be innumerable deposits of small tubercles miliary.
The disease may run its course as an acute-fibrinous pleurisy, or the more insidious form of the subacute variety, or become prolonged as chronic pleurisy. Either form may be complicated by pericardial or peritoneal tuberculosis. The exudate is sero-fibrinous in character, and not infrequently is stained with blood.
Diaphragmatic Pleurisy.—In this variety the diaphragmatic portion of the pleura is involved, the pain being located at the insertion of the diaphragm to the tenth rib and extending to the epigastric region. The pain is intense, the patient assuming the sitting posture, slightly bent forward. The respiration is short, catching, and chiefly thoracic. Nausea and vomiting often occur, which greatly adds to the patient's suffering, as does the cough which attends it. The effusion is generally small in quantity, and may be either plastic, sero-fibrinous, or purulent. If purulent, there may be bulging of the intercostal spaces. The temperature range is high in this form, the pain more exquisite, and the patient presents a more anxious expression than in any other form.
Encysted Pleurisy.—As the result of adhesion, the effusion may occupy two or more circumscribed pockets, which may or may not communicate with each other, and may occupy various positions. The symptoms are not pronounced and therefore may be quite difficult of detection. Where percussion reveals circumscribed dullness, with resonance at its border, the character of the lesion would be suggested, which would justify an exploratory puncture with a trocar.
Interlobar Pleurisy.—This form is usually preceded by, or associated with, sero-fibrinous pleurisy, and results from adhesions cutting off the interlobar spaces from the general pleural sac. The encapsuled exudate varies in size from a small egg to a cocoanut, and is found more frequently in the right side than in the left, and between the upper and lower lobus, near the root of the lung.
The symptoms are not characteristic, and after a long period of ill health the abscess may discharge into a bronchus, the expectorated pus being the first indication of a chest lesion. When the abscess is large, the symptoms will be more like that of abscess of the lung.
Hemorrhagic Pleurisy.—This variety is where blood is found in the effused fluid, and in sufficient quantity to be recognized by the unaided eye, and is nearly, if not always, associated with tuberculosis or carcinomatous conditions of the lungs or pleura, or to Bright's disease, cirrhosis of the liver, or low forms of acute, infectious diseases. It is sometimes accidental and the result of puncture by the trocar.
Diagnosis.—If care be taken in noting the physical signs, there will be few mistakes made in the diagnosis, though several lesions might be mistaken for it, if examined superficially. We are to differentiate sero-fibrinous pleurisy from pneumonia. In pneumonia, in addition to the sudden onset, there will be a higher range of temperature, deep flush of the cheeks, the pain will be more diffuse, the cough attended by expectoration of rusty sputum, and there will be a dull sound rather than a flat one on percussion. There will be but little or no distention of the thorax.
Palpation will reveal marked fremitus, save where there is obstruction of a bronchus. Auscultation gives crepitant and sub-crepitant rales, and later bronchial breathing and no friction sound; and, lastly, there will be no displacement of neighboring organs.
Hydrothorax is usually associated with renal or cardiac disease, has little or no fever, absence of sharp, stitchlike pain, no friction sound, is often bilateral, and the specific gravity of the fluid is below 1.015, while that of pleurisy is above 1.017.
Pericardiac effusion may be mistaken for sero-fibrinous pleurisy of the left side, but the history of the former, which tells of rheumatism, the marked dyspnea, the feeble heart-sounds, the normal position of the heart, and the resonance heard on the posterior chest-wall and at the base of the lung in the postero-lateral region, will distinguish the one from the other.
Tumors and cysts reveal a different history. They are rarely attended by fever, are not accompanied by uniform distention, the dullness is more often confined to the upper and middle portion of the lung, and the respiratory murmurs are absent owing to compression of the lung.
Echinococcus cyst of the liver or abscess might be mistaken by crowding upward the lung, but the boundary-line of dullness will show convexity, and the history of the case will be of such a nature as to assist materially in fixing the disease, and the aspirating needle will remove all doubt.
Prognosis.—The prognosis is usually favorable, though much depends upon the etiologic factor. Where the disease is primary, the affection runs a much shorter and more favorable course. If secondary to tuberculosis, or carcinoma, the outlook would be correspondingly bad, and the course of the disease would be of a longer duration. The fever, inflammatory stage, lasts from one to three weeks, during which the effusion takes place, and this is followed by the non-febrile stage, which may last for weeks or months.
Treatment.—The treatment in the early stage will be sedative in character, for just in proportion to our ability to control the inflammatory process, will we control the exudation of serum.
Veratrum.—Occasionally we find a full, strong, bounding pulse showing excessive heart power, great excitation, and high grade of inflammation. With these symptoms the patient will be restless and suffer excruciating pain. If not overcome, these conditions lead to grave results. In such cases veratrum is one of the best remedies in the materia medica, and we give it in tangible doses, carefully watching its effects, however, and as the pulse comes under control, the temperature falls, the skin relaxes, and the pain subsides, we lessen the size and frequency of the dose. Our prescription with the above indication would read:
|Aqua||4 ounces. M.|
|Sig. Teaspoonful every one, two, or three hours.|
Aconite.—Many cases will have the small, frequent pulse, and aconite will replace the veratrum, but this remedy will always be used in the small dose. Thus:
|Aqua||4 ounces. M.|
|Sig. Teaspoonful every hour.|
Asclepias.—This is a splendid remedy in pleurisy. Where the pain is erratic, the skin dry, and the tissues tense, asclepias, one or two drams to half a cup of hot water, a teaspoonful every thirty or sixty minutes, for several doses, will produce relaxation, diaphoresis, lessen pain, and control inflammatory processes.
Bryonia.—This is one of the best remedies for inflammatory conditions of the chest that we possess, for its usefulness is not confined to the acute stage, but is equally efficient where effusion exists. Where the pulse is quick and hard, where there is sharp, stablike pain, and flushed, bright cheek, bryonia, 10 drops; aqua 4 ounces; teaspoonful every hour, will prove very beneficial. Many times it will prevent extensive effusion of serum, and, when present, it assists materially in hastening the process of resorption.
Rhus Tox.—Where there is irritation of the cerebro-spinal centers, as shown in the small, sharp, hard pulse, elevated papilla on tongue, restless condition of the patient, insomnia with burning sensation in chest, rhus tox., 10 drops; aqua 4 ounces; teaspoonful every hour, will give results.
Macrotys.—Where the pain is located in the muscular structure or is rheumatic in character, we add from a half to a teaspoonful of the tincture to the sedative solution. Where these remedies are faithfully given, the effusion will be limited in quantity, and generally will be reabsorbed. In the way of local measures, libradol is perhaps the most efficient agent. It should be renewed as often as it becomes dry, which will be about twenty-four or thirty-six hours.
Where the effusion is large in quantity and of long standing the old compound tar-plaster will serve a better purpose; it should remain on until it produces suppuration, when the surface will be dressed with a simple cerate. If the fluid produces dyspnea and medication fails to bring about absorption, paracentesis should be performed.
The patient should be sitting up, leaning slightly forward, and the arm of the affected side thrown across the chest, with the hand on the opposite shoulder. A large aspirating needle, properly sterilized, is introduced, if on the left side, in the seventh interspace in the mid-axillary line. The needle, with boring motion, is made to enter the chest just above the upper border of the rib, the needle slightly upward. If the right side be affected, the puncture is made in the sixth interspace in the same way.
If there is a large quantity of fluid and it is of long standing, it is not best to attempt to open the cavity. The amount drawn will depend somewhat upon the effect it has upon the patient. From ten to twenty ounces may be removed at one operation; but if dyspnea, cough, and pain attends the operation, the needle must be at once withdrawn. If the accumulation be recent or an active fever be present, a much larger quantity may be withdrawn. On the removal of the needle, the puncture is to be covered with an adhesive strip. If the fluid repeatedly accumulates, the patient is probably tubercular, and recovery is not apt to follow.