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.