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The Pamphlet Collection of Sir Robert Stout: Volume 28

Chapter V. — Pleurisy

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Chapter V.

Pleurisy.

Of all diseases causing cough, perhaps the most common with the exception of bronchitis, is pleurisy. It is exceedingly rare to find on examining the body of any adult person, that there are no adhesions between the pleura covering the lungs, and the pleura lining the chest. And even among children who have passed the age of eight or ten years such adhesions, which always indicate former inflammation, are very common.

The pleura is a smooth shining membrane which lines the inside of the chest, and is reflected over the lungs. In the healthy state the lung pleura is entirely unconnected with the chest pleura, except at the root of the lung; but when the pleura is inflamed the membrane is roughened by the effusion of plastic lymph, and fluid is poured out. If this fluid is small in quantity, and the inflammation is not extensive, it is soon absorbed, but nearly always adhesions of fibrous membrane are formed between the inflamed portion of pleura and the lung, or side of the chest, opposite to it.

The symptoms of the majority of cases of pleurisy are very slight. Indeed very few of the persons who are found after death to have suffered from the disease, have ever been aware of its existence during life. A stitch in the side, and a short dry cough, are hardly noticed when they occur, and are very rarely treated by medical men. Once I had an opportunity of observing a case of this slight kind. A young friend and pupil of mine complained one day of pain and aching much increased by a forcible inspiration at the top of one lung. I examined the place with the stethoscope, and found the dry, rough, nibbing sound which indicates pleurisy, together with a slight degree of that peculiar modification of the vocal resonance called ægophony. Two or three leeches were ordered, and in a few hours the pain and the other symptoms ceased.

Pleurisy, as has been before mentioned, generally accompanies pneumonia. When this is the case the same treatment is used for both in the early stages, but if, as sometimes happens, the fluid effused is not absorbed very readily, a blister may be applied, and a little iodide of potassium, or tincture of iodine given, and it soon disappears.

An acute attack of pleurisy, involving a considerable surface, is not likely to be overlooked. The attack is generally ushered in with shivering, followed by flushes of heat, thirst, loss of appetite, quick hard pulse, hot skin, and the other symptoms of sympathetic fever. At the same time there is sharp cutting pain in the side, generally under one nipple, page 23 a short dry hard cough, which is suppressed as much as possible, in order to avoid the great increase of pain in the side which accompanies it. The breathing is short, shallow, and hurried, and there is often an anxious expression about the countenance. As the disease advances the pain in the side diminishes, because fluid is poured out into the pleural cavity, and the two inflamed surfaces no longer rub against each other, but the cough is more troublesome, the breathing more hurried and shallow, and it length if one side of the chest is filled with fluid as often occurs, very alarming and dangerous difficulty of breathing conies on. When this happens the patient is obliged to sit up constantly, because when he lies down a feeling of suffocation comes on, which compels him to rise immediately. If the patient is feeble, and proper means are not adopted, death may take place; but if effectual remedies are used, death never need occur in uncomplicated pleurisy of one side only.

In pleurisy on the left side, when the chest has become full of fluid, the heart is pushed quite over, and may be felt beating on the right side.

Chronic pleurisy may either be the result of an acute attack neglected or badly treated, or may be a disease of itself. In either case it presents much the same features as the acute attack, but modified in severity. There may be one side of the chest filled with fluid, water on the chest as it is commonly called; but the breathing is not so hurried, because the chest has had time to adapt itself to the pressure of the fluid. After a time however, and in all cases of pleurisy from perforation in consumption the effused fluid becomes purulent, or in other words a vast collection of matter is formed in the chest. Then the symptoms of hectic fever arise, and unless relief is afforded by tapping the chest, death soon occurs.

The treatment of a case of uncomplicated pleurisy in a moderately healthy person, is extremely simple. In no disease with which I am acquainted is so much relief afforded by local blood-letting. Even in weakly persons a few leeches can do no harm, and they almost immediately relieve the pain and difficulty of breathing. In robust healthy persons the number of leeches may be increased, or a few ounces of blood taken by cupping. The patient should be kept strictly at rest, and no talking or exertion of any kind allowed. The chest should be kept constantly fomented or poulticed, and if the pulse is hard and quick, small doses of antimony or aconite should be given. The bowels should be regulated; the diet of a non-stimulating but sufficiently nourishing kind—anything like starvation being carefully avoided, and a dose of Dover's powder given at night. Under this treatment a few days or even a few hours will see the end of all acute symptoms. Should there be, on auscultation, signs of fluid remaining, a mister should be applied, and repeated if needful, and from three to five grains of iodide of potassium, given in infusion of gentian or calumba, three times a day.

I have never seen this kind of treatment fail in uncomplicated cases. When pleurisy arises as it often does, during an attack of acute rheumatism, it is more difficult to manage. Generally the pericardium is inflamed at the same time, and there is fluid surrounding the heart, and greatly impeding its action. I have seen cases in which both pleural cavities were half filled with fluid, and the pericardium enormously distended too. Yet recovery will take place. The first thing page 24 to do is to subdue the rheumatism; this is easily managed, but it by no means follows that the pleurisy disappears with the rheumatism that caused it. The treatment of these cases taxes the skill and care of the physician to the very utmost. It may be necessary to tap the chest and draw off the fluid, in order to prevent impending suffocation. At the same time it is often necessary to administer stimulants freely in order to sustain the powers of the system. Even in very extreme cases I have seen large blisters afford wonderful relief. I have seen a single blister of large size, lessen the depth of fluid in the pleura by the breadth of four fingers, in twenty-four hours. At the same time every other means should be taken—by means of diuretics, purgatives, when the strength will allow—and other means to get rid of the fluid. Among the most efficacious of these measures is the administration of iodide of potassium.

Chronic pleurisy must be treated chiefly by the administration of iodine, and tonics, together with other measures calculated to improve the general health, if the patient is weak, as is usually the case, iron, especially the syrup of the iodide in full doses, quinine or cinchonine, and cod liver oil, may be found beneficial. But the main reliance must be on iodine and blisters. The following mixture I have seen very useful:—

Iodide of Potassium, half a drachm
Syrup of Iodide of Iron, two drachms
Compound Tincture of Gentian, one ounce
Peppermint Water, seven ounces, R

Take a sixth part three times a day.

Blisters may be applied one after another as fast as they heal. Four or five, combined with other remedies, will be sufficient for the severest cases of chronic pleurisy, provided the fluid has not become purulent. If this should be the ease, tapping the chest is the only remedy. In slight cases of chronic pleurisy, one blister, followed by painting the chest with strong iodine paint, will answer as well as several blisters.

I have never found it needful to give mercury in these cases, and though I have seen it given in hospital practice, I never saw any good result from it.

Neglect of these cases, in which there has been a great quantity of fluid poured forth, often causes great deformity of the chest, when the fluid is absorbed. For, after a time, although medicine or the natural powers of the system may cause absorption of the fluid, yet the lung is so bound down by adhesions that it cannot expand, and the pressure of the atmosphere causes contraction of the chest.

Although in these, as in all cases, the chief care should be directed to the removal of the essential disease, yet as cough is often very severe and exceedingly painful, it will be necessary to treat it separately. Now for the relief of this symptom, nothing is more efficacious than Dover's powder in doses of ten to fifteen grains. Given at night, one of these powders will often ensure a tolerable night's rest, when without an opiate there would be nothing but incessant coughing. *

* The sedative solution of opium in doses of twenty minims, and the solution of morphia in the same dose, may also be used, if Dover's powder causes sickness, as it sometimes does.