DISEASES OF THE PLEURA
Pleurisy
Definition.—An inflammation of one or both pleural membranes.
Varieties.—Etiologically, it may be divided into primary and secondary pleurisy; also, into acute and chronic pleurisy. Anatomically, the cases may be divided into dry pleurisy and pleurisy with effusion (serofibrinous, purulent, hemorrhagic).
Acute Pleurisy
(Fibrinous or Plastic Pleurisy)
The affection may be primary or secondary. As an independent affection it is rare. It may follow exposure to wet and cold or it may be due to mechanical injury. The disease may set in with pain in the side, slight fever and the friction sound of pleurisy may be present. These symptoms last a few days and then disappear and no exudation occurs. The pleural surfaces become more or less united.
As a secondary process, dry plastic pleurisy arises from extension of the inflammation in acute or chronic diseases of the lung, especially pneumonia. Abscesses, gangrene and cancers are also causes. It sometimes occurs in acute articular rheumatism, and in a large number of cases is associated with tuberculosis. This condition may be a complication in chronic Bright’s disease and in chronic alcoholism.
In the fibrinous form of pleurisy the serum is scant and the membrane is covered with a sheathing of lymph, which finally organizes and adhesion takes place between the opposing surfaces.
Serofibrinous Pleurisy
This form is known as pleurisy with effusion. There is little lymph, the exudate being mainly composed of serum.
Osteopathic Etiology and Pathology.—Many cases rapidly follow exposure to cold, wet or an injury to the thorax. Exposure to cold is considered a mere predisposing agent, permitting the action of various micro-organisms. The large majority of cases are due to tuberculous infection of the pleura.
The osteopath finds that important predisposing causes of pleurisy are injury to the chest wall, ribs and vertebræ, and exposure to cold, causing contraction of the thoracic muscles. These injuries and strains throughout the chest result in an interference with the intercostal and phrenic nerves, and also with the intercostal and internal mammary arteries; consequently, there is produced a lowered vitality of the pleural tissues, which permits the attack of the micro-organisms. It may be secondary to rheumatism, Bright’s disease, cancer and cirrhosis of the liver.
Pathologically, there is an abundant exudation of serum. Fibrin is found on the pleura, and is rarely abundant in the serous fluid in the form of flocculi. The fluid is straw colored as a rule. It varies greatly in quantity from one-half to four litres. Microscopically, there are found leucocytes, red blood-corpuscles, shreds of fibrin and occasionally cholesterin, uric acid and sugar. The composition of the fluid resembles blood serum, and is rich in albumin.
Various displacements of the adjacent organs are caused by the effusion. The lung is more or less compressed into the back part of the pleural sac. The heart is displaced. The diaphragm may be crowded downward. On the right side this lowers the liver; on the left it displaces the stomach, transverse colon and sometimes the spleen.
Symptoms.—The onset may be abrupt with a chill, severe pain in the side and fever. With few exceptions the disease comes on insidiously, pain in the side being the first symptom. The pain is sharp and cutting and is aggravated by breathing or coughing. There is moderate fever, the temperature ranging from 102 to 103 degrees F. Dyspnea may be present at the onset. This is due to the fever and pleuritic pain. When the fluid is effused slowly, dyspnea may be absent except on exertion. It is most marked when the effusion has developed rapidly. As the effusion accumulates and the inflamed surfaces separate, the pain diminishes and, as a rule, soon disappears.
Physical Signs.—Immobility and bulging of the affected side, depending on the amount of exudation. The intercostal spaces are obliterated. The apex beat of the heart is displaced. Upon palpation the limited movement of the chest is more accurately determined. Tactile fremitus is largely diminished. The position of the heart’s impulse can be readily located by palpation. Displacements of the liver and spleen can be felt through the abdominal walls. At first the percussion notes are impaired and later there is dullness which gradually rises as the fluid increases. The upper line of dullness is not horizontal when the patient is in the erect posture, but is higher behind than in front. Above the effusion in the sub-clavicular region, percussion gives a tympanitic note, the so-called Skoda’s resonance. In moderate effusions the level of dullness often changes with the position of the patient. Early in the disease a friction rub can usually be heard. As the fluid accumulates, the breath sounds become weak, distant and may have a tubular or bronchial quality. Vocal resonance is usually lessened. There may be bronchophony, or it may manifest a nasal or metallic quality, resembling somewhat the bleating of a goat (Lænnec’s egophony). X-ray examination should be made.
Duration.—The course is extremely variable. The fever is due to inflammation and may last for two or three weeks, when it may subside. The cough and pain disappear and the effusion, which is usually slight in these cases, may be absorbed quickly. In cases where the effusion is poured out rapidly it may be absorbed just as quickly. In cases where the effusion is poured out slowly or where the effusion reaches as high as the fourth rib, recovery is usually slower. Large effusions may persist without change for months and finally the case may become subacute or chronic. This is particularly true of tuberculous cases.
Prognosis.—This depends largely upon the cause; on the whole, prognosis is favorable. Death is a rare termination of serofibrinous effusion; death may, however, occur suddenly without sufficient lesions to explain the cause. The exudate may become purulent.
Treatment of Acute Pleurisy
An early treatment and rest in bed with a liquid diet are the measures to be employed at the beginning of the attack. Pay particular attention to any primary disease and to the general health. Rarely is there any difficulty in locating certain predisposing causes of the disturbance. Then often a rib or corresponding vertebra is badly subdislocated over the seat of the disease. The sympathetic and phrenic nerves are involved through the intercostal and phrenic nerves. A careful examination of the side of the affected chest should be made, as there may be more or less obstruction of the intercostals and the internal mammary arteries from their branching of the aorta and subclavian vessels. A dislocation of the first or second rib may affect the subclavian vessels and their branches markedly; although all the upper ribs and the thoracic muscles should be examined carefully for derangements which would affect these blood-vessels and produce an exudation. Ice-bags upon the chest, as in pneumonia, may be used. Limiting the movements of the chest with a bandage or adhesive strips will give considerable relief.
When the effusion has taken place, carefully raising and spreading the ribs with attention to special points of involvement, will at times cause absorption of the fluid. The daily amount of liquid food should be greatly lessened with a view of depleting the blood serum from various tissues; thus the serum collecting in the pleura, which is a lymph space, will also be absorbed. Treatment of the bowels, kidneys and skin, so that they may be rendered active, will aid in the depletion of the blood serum.
It may be necessary in some cases to aspirate, especially if other methods fail and if the effusion is large. The points of operation are in the mid-axillary line at the sixth interspace or at the angle of the scapula at the eighth interspace. In puncturing, the needle should be held close to the margin of the upper rib so as to avoid the intercostal artery. Withdraw the fluid slowly and if faintness is produced, desist.
Empyema should be treated surgically. Simply tapping is rarely sufficient. A free incision, as in abscess, and thorough drainage should be made. Care must be taken that the drainage tube is large enough.
“In cases of pleurisy the axilla and the inner arm may be tender and painful; this is due to the pleuritic inflammation being carried by the way of the ‘nerve of Wrisburg.’
“The pleuritic pain in the costal muscles compels restricted movement of the ribs and also limits the respiratory function of the diaphragm. These painful cramps and stitches are independent of the pain arising alone from the inflamed pleural surface, and the diminution of the respiratory movements is due to a particularly contractured state of the muscles of the chest as is demonstrated by the fact that the patient can not draw a long breath; hence one may reasonably conclude that nature has so distributed nerves to the pleura as to enable that serous membrane to control the muscles which create movements of the adjacent costal surfaces and thus insure its quietude during the stages of inflammation or repair.” (Ranney).
Chronic Pleurisy
Definition.—Chronic inflammation of the pleural layers. There are two forms, exudative and dry or plastic pleurisies.
Chronic Pleurisy with Effusion.—This may follow an acute serofibrinous type. Some cases develop very slowly. In most cases in children, the fluid changes to pus early in the disease. The fluid may remain for months without changing to a purulent character. In such cases the character and physical signs do not differ from those in acute serofibrinous pleurisy.
Chronic Dry Pleurisy.—These cases originate in two ways:
First, this may succeed pleural effusion when the fluid portion of the exudate is absorbed and the pleural layers are opposed. They are separated only by fibrinous elements that become organized into firm connective tissue. This process goes on at the base, principally, which, if it follows the acute form, produces but slight flattening, but if it succeeds the chronic form or empyema, the extent of retraction and flattening will be marked. Calcification may occur in these firm, fibrous membranes and occasionally little pouches of fluid are found between the false bands.
Second, a large number of cases are dry from the onset. This condition may follow directly acute plastic pleurisy. It may be of tuberculous origin or it may set in without any acute symptoms. No matter how slight the plastic exudate may be, it invariably tends to become organized, thus producing adhesion of the layers. This is undoubtedly the result when the pleurisy is primary or secondary. The adhesions are generally circumscribed. When the adhesions are of tuberculous origin they may be locally confined to one pleura or they may be bilateral. In these cases both the parietal and costal layers are thickened, and embodied in the thickened pleura are found firm fibrin masses and small tubercles.
Occasionally, vasomotor symptoms arise in chronic pleurisy, especially in cases of tuberculous origin, and are probably due to the involvement of the first thoracic ganglion. These almost invariably mean that there is a displacement of the first, second, or third rib. Unilateral flushing or sweating of the face or dilatation of the pupil are frequently noticeable.
Symptoms.—Definite symptoms are rarely present. In some cases the physical signs are quite pronounced, while, on the other hand, they may be entirely negative. In mild cases there may be slight immobility of the affected side with feeble breath sounds. In other cases there may be very full chest expansion while the breath sounds are feeble. In a large number of instances the physical signs are quite distinct. There is displacement of the viscera, retraction of the chest walls, curvature of the spinal column and dropping of the shoulders. There are feeble breathing and creaking, leathery friction sounds. Dullness is found at the base.
Treatment.—The treatment of chronic pleurisy is largely that of acute pleurisy. Gymnastic and methodical breathing exercises should be employed in helping to correct the thoracic walls. Care must be taken not to injure the chest and pleura if adhesions have formed. Surgical work may be necessary in some cases.
The vasomotor symptoms that are sometimes manifested in chronic pleurisy and are claimed to be due to involvement of the first thoracic ganglion, are an interesting feature to the osteopath. Such cases would probably present to the osteopath a marked lesion of the upper dorsal vertebræ or the second or third rib. These vasomotor symptoms are also found in pleurisy associated with tuberculosis of the apex of the lung.
The osteopath frequently treats these cases and he should be cautious about over-treating or straining the chest wall. The adhesions are persistent and often there is more or less pain, so care must be exercised when attempting to structurally readjust. Do not expect to completely relieve every case, but nevertheless there are few cases but that can be benefited. Occasionally the pain alone is due simply to pleurodynia.