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Whenever inflammation occurs anywhere except on a mucous surface, there occurs what is called an exudation. This is familiar to us in the examples of inflammation which take place at or near the surface of the body ; a boil, for example, is a circumscribed inflammation, and we are well aware of the fact that a considerable amount of material is deposited in the inflamed spot, making a swelling. So, too, in acute rheumatism, a large amount of liquid or exudation takes place into the joint, resulting again in swelling. When the membrane covering the lungs becomes inflamed, a simi lar exudation of liquid takes place into the space between the ribs and the lung. The amount of this exudation varies considerably, amounting sometimes to several pailfuls. The result of the pres ence of this liquid in the chest is, of course, to compress the lung and interfere seriously with breathing.
Symptoms.-There is usually no premonitory stage preceding an attack of pleurisy. An individual exposes himself to cold, gets his feet wet, or is caught in a heavy shower ; after an interval which may vary from a few hours to several days, the patient experiences a shivering sensation, which may sometimes develop into a pro nounced chill. About the same time he begins to feel considerable pain in one side of his chest. This pain is usually sharp and cut ting in character, increases during the act of breathing, to such an extent that the individual unconsciously arrests the motion of his chest on that side. Any violent motion, particularly coughing and sneezing, is accompanied by exquisite pain ; and even the ordinary movements of the body occasion considerable uneasiness. The pain is usually referred to the middle and lower part of the chest, especially in front and under the arm ; it may not be limited to any particular spot, but may seem to spread over the entire side. Meanwhile, the chill has been followed by fever, which is not, however, extreme. The usual evidences of constitutional indispo sition- thirst, wandering pains, headache, restlessness and debility -are usually present ; yet it is not seldom to observe a case in which most of these symptoms are wanting - the patient complain ing almost exclusively of the sharp sticking pain in his side upon breathing.
Such are the symptoms during the stage of inflammation which precedes the exudation - that is the escape of liquid into the cavity of the chest. When this exudation has occurred, the symptoms change materially ; the pain is much diminished, pre sumably because the inflamed surfaces which had been previously rubbing against each other during every act of breathing, are now separated and bathed by the liquid exudation. The acts of cough ing become less frequent and less painful; the fever subsides somewhat, and may even cease ; the patient feels more comfortable, acquires a little appetite, and may even rise from his bed and walk about. If the amount of exudation which has been thrown out into the cavity of the chest be so considerable-say several pints - as to compress the lung on the same side of the chest, the breathing will be hurried, since the individual now has the use of but one lung ; if the amount be excessive, the respiration is extremely rapid ; the skin may be blue, indicating that the patient gets an insufficient quantity of air; he is often compelled to sit upright, in which position he is enabled to breathe easier. Yet there is considerable diversity in the symptoms, even when one side of the chest is distended with fluid. Cases are sometimes seen in which, even under these conditions, the patient is perfectly com fortable, and seems to suffer from no lack of air.
Another sign that the exudation has occurred, is more apparent, perhaps, to the non-professional eye than those just discussed ; it consists in the change of position of the patient, for during the first stage, before the water has been poured out into the chest, that is, while the inflamed surfaces are rubbing against each other, the patient cannot bear to lie upon the affected side ; he reclines, always, either upon the back or upon the healthy side. So soon as the exudation has occurred, on the other hand, he finds most comfort when lying upon the affected side, for now this gives him no pain, but permits him to use the healthy side for breathing.
The further course of the disease consists, in the majority of cases, in the removal of this liquid again from the chest cavity, leaving the chest in almost the same condition as before the disease began. This, however, is a gradual and often a long process. Weeks may elapse, even after the patient is apparently convalescent, before all the liquid has been taken from the chest. On the other hand, it sometimes happens that the liquid is not promptly removed from the chest, that a considerable quantity of it may remain for months, retarding the patient's recovery, and perhaps requiring ultimately artificial means for its removal. A still worse sequel to the disease consists in the gradual formation of matter - suppura- tion - in the cavity, so that the liquid becomes gradually transformed from water into pus. This constitutes the affection known as empyema, which may entail the most serious consequences, and will be later discussed.
In the majority of cases the liquid is sooner or later entirely removed from the chest cavity. In the most favorable cases the compressed lung regains its former size and use so soon as the com pressing liquid is removed, and the patient may recover the entire use of the lungs and chest, so that even a careful medical examina tion can detect no trace of the disease. In a considerable number of cases there remain, however, certain reminders of the affection, in the shape of deformity of the chest. This results from the fact that there have been formed during the inflammation certain bands which unite the lung and the chest wall, preventing free movement of the chest in breathing. In such cases the ribs may be sunken, instead of bulging in the natural way; the entire side is smaller, and the back bone may be curved toward the opposite side, causing the shoulder of the diseased side to be lower than the other one. Some cases of serious curvature of the spine originate in the facts of pleurisy during childhood or youth. Acute pleurisy, when occurring spontaneously or as the result of taking cold, usually affects the entire side. It may, however, occur as a sequel and result of some other inflammation, such as pneumonia and consumption. As will be remarked later, pleurisy is responsible for many of the pains which occur during the course of consumption. It may also be produced in consequence of a wound which penetrates the chest, or of the fracture of ribs, even without any wound to the skin ; it may also be developed as a sequel of scarlet fever, measles, and of the infectious diseases generally.
The disease may occur at any time of life, although it is extremely rare in infancy and in old age ; it affects males far oftener than females.
Treatment.-Pleurisy itself is not ordinarily a grave disease, though some of its possible sequels may be serious. The disease usually subsides even without treatment ; yet the patient's comfort can be materially enhanced by certain measures. During the first stage the object is to arrest, if possible, the course of the inflammation, or at least diminish its intensity, with the hope of restricting the amount of exudation which is to follow. We know of no means which can be relied upon for arresting the disease. In former years blood-letting, opium and mercurials were largely employed for this purpose, but have all been abandoned. It will usually be found that some form of opium will be necessary for subduing the pain ; for this purpose we may employ an eighth of a grain of morphine. But a better measure will be ten grains of Dover's powder, in which we obtain not only the sooth ing effects of opium, but also secure free action of the skin. If the temperature be high, the patient should be either freely sponged or may take a hot bath. Much relief will be afforded by applying to the chest, over the painful part, either cotton wool covered with oiled silk, or a light poultice of flaxseed. Regular evacuations of the bowels should be secured by the use of saline laxatives, if any medicines be necessary.
When the escape of the liquid into the chest cavity-the exuda tion- has occurred, measures are usually adopted for the hasten ing of the removal of the liquid again. For this purpose the chest is usually painted with the tincture of iodine, or several blisters are applied in succession, and permitted to remain until the skin is fairly raised. In obstinate cases there can be no doubt that these measures, the iodine and the blisters, may accomplish the desired object. Yet, until there is some evidence that the case is proceed ing less rapidly than usual, it is doubtful whether any such meas ures should be used. Another plan, which may be combined with the local application to the chest, consists in the administration of saline cathartics to such an extent as to cause several evacuations of the bowels every day ; or, the following prescription may be given :
Powder of squills - One drachm.
Powdered digitalis - sixteen grains.
Mix and divide into sixteen pills ; take one three times a day.
The object of this is, of course, to remove the liquid from the chest, causing it to be taken into the blood and pass out with the evacuation from the bowels. It must be said, however, that this plan is not so successful in the removal of water from the chest, as in the removal of water from the legs or from the abdomen, that is " dropsy. " It often becomes necessary to employ mechanical means for this purpose, to make an operation which is known as aspiration of the chest. This consists in introducing a fine needle into the cavity of the chest, between two adjacent ribs, and in attaching a syringe so that the fluid can be withdrawn without per mitting any air to enter. In this way the chest cavity can be easily emptied, without causing the patient any more pain than the prick of the needle. Yet it is a fact that the liquid usually returns in this cavity, and has to be removed again. However, the result sought can be finally secured in the great majority of cases.
During convalescence the patient's strength must be of course invigorated by the usual strengthening diet, and by the use of tonic remedies, especially iron. If the lung be bound to the chest wall by bands, as above described, much maybe done by persistent and systematic efforts to dilate the lung by deep inspirations. This practice should be continued for months, perhaps even years; it is certainly sometimes possible to restore the natural form and functions to a chest which seems permanently damaged.
It sometimes happens that both sides of the chest will be inflamed at the same time; that there is in fact a double pleurisy; this of course increase the gravity of the case, since all of the ill effects are doubled. It may also happen that while the patient is convalescent from a pleurisy on one side, he is attacked by the same inflammation on the other side of the chest. Yet these cases not infrequently recover, however serious they may appear for a time.
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