During the pyrexial period aspiration is said to be very liable to be followed by a reaccumulation of the exudate.
It is often observed that the with drawal of a comparatively small quan tity of even a very large effusion is fol lowed by rapid absorption of the re mainder. This is probably due to the removal of excessive pressure from the pleural lymph-vessels, allowing of their dilatation and of a free flow of lymph.
In nineteen cases of pleural effusion the removal by aspiration of a single cubic centimetre influenced favorably the absorption of the fluid and caused in creased excretion of urine. Effect of this treatment is due to traumatic irritation. Jordan (Pester med.-chir. Presse, No. 25, '94).
In small effusions the puncture with the aspirator-needle must, of course, be made over the seat of effusion. When the effusion is large, so that the pleural cavity is nearly full, the best place for puncture is outside the angle of the scapula or in the middle line of the axilla, on a line with or a little below the nipple; that is, about the seventh inter, costal space; as here the intercostal spaces are wide and the chest-wall thin. These places are safe unless the lung is adherent. The suction of the aspirator should be sufficient only to maintain a gentle flow of fluid. The flow is to be stopped as soon as the suction causes frequent cough, pain in the chest, or blood to appear in the flow.
The pain of puncture may be relieved by previously freezing the skin or by in filtration anaesthesia. It is best to incise the skin with a bistoury and then to in troduce the needle with a sudden thrust, so that it may penetrate the layer of fibrin on the costal pleura and not carry it away from the chest-wall. Frequently the needle becomes obstructed by a frag ment of lymph in passing through the fibrinous layer or by particles floating in the scrum. Occasionally a case is met with in which the fluid will not flow on account of the lung being so bound down that it cannot expand. In such we must be content with the few ounces that can be withdrawn.
Pleurisy is always to be treated as a serious disease; particularly if it is suspected to be of tuberculous origin special efforts are to be made to secure complete absorption of the exudation and full re-expansion of the lung. Nu
trition should be maintained at the high est point possible by favorable sanitary conditions, by an abundant supply of suitable food, and by such medication as the special features of the case call for. Gradually increasing doses of creasote have appeared to be beneficial in some cases. Out-of-door life is as necessary in this as in other forms of tuberculosis. If retraction of the chest is progressive after disappearance of the fluid, resi dence in high altitudes may be desirable to stimulate expansion of the chest by breathing rarefied air.
Much may be done by the systematic practice of deep inspiration followed by slow, obstructed expiration. For chil dren this may be effected by blowing bubbles or by having two large bottles, one empty and the other filled with water, connected by tubing and a suit able tube with mouth-piece inserted into the full bottle and the child encouraged to force the water over into the empty bottle by blowing into the full one. This may be done several times a day.
Every chronic inflammatory process in either lung or pleura that is not already infected with tubercle bacilli is in con stant danger, of becoming so. Hence, all such subaet,. .processes should be care fully watel: d treated until every trace of disc has disappeared. Fluid in the pleur compresses the lung so that rep must be carried on • upon the side; the muscles on the diseased .:trophy from disuse. If these atroll museles are not strength ened by prop 4.;ymnasties a feeble re spiratory actin t is present, especially at the base, and hence becomes a fertile field for the growth and multiplication of tubercle bacilli. All fluid accumula tions should be gotten rid of as soon as it is evident that Nature will not absorb them. The reappearance of fever, after it has disappeared from the acute stage, is strongly suspicious of the presence of pus, which should be promptly evacuated and the cavity thoroughly drained. James (Penna. Med. Jour., Nov., '97).