PARACENTESIS THORACIS. — Aspira tion or simple puncture with a long hy podermic needle is performed as fol lows:— 1. The skin in the intercostal space selected is cleansed with soap and warm water, followed by alcohol, and a car bolic-acid solution of to 100.
2. The needle is asepticized by passing through an alcohol-lamp.
3. The skin is held up and the fact ascertained that there is space enough between the upper surface of the rib and the course of the needle.
4. The needle is then suddenly plunged so as to penetrate the pleura.
5. After removal of the needle the wound is closed with collodion and cotton.
When a vacuum instrunient cannot be secured, the surgeon should use devices at his command in preference to await ing the more convenient forms of appa ratus. He can attach a rubber tube to a trocar and cannula, if he is careful to hold the finger upon the outlet of the cannula as he removes the stylet. It would be well to insert a rubber tube into an antiseptic solution, so that the fluid may lie carried into it, and no concern need then be felt as to the fluid ceasing to flow, when air would enter if the ex ternal orifice of the tube were out.
The exact directions in paragraph No. 3 are based upon the course of the inter costal artery, which is in a groove on the inferior surface of the rib, while the skin should be raised so that a valvular open ing shall be made. When the needle is removed, the puncture is not open con tinuously and shuts out the air.
The thorough preparation of a patient even for so simple a procedure as aspira tion, is necessary.
The best and most efficacious drug is strychnine nitrate injected hypodermic ally before an operation. The combina tion of 1/„, grain of strychnine, with V, grain of morphine, 1/,„ grain of atro pine, and 3/, grain of cocaine hydro chlorate, may be injected preparatory to aspiration.
The patient is placed on the sound side, and the arms folded over the chest, so as to draw the scapulm away from the vertebrce. This affords a safe method of
selecting the interspace between the sixth and seventh rib in the posterior axillary line. It may be found at the extreme angle of the scapula, and with a space comparatively free from muscles, where the ribs are some distance apart. The most expedient course, however, is to count the ribs also, and to have a needle at least three inches in length which is attached to a Potain or Dieula foy aspirator.
The most dependent portion of the collection should be selected in small ac cumulations.
The diaphragm has its lowest attach ment behind at the twelfth rib and on the sides about the ninth or tenth, but the collection of pus may be incapsulated so as to present definite indications for puncture as low as the eighth intercostal space in the middle axillary line; behind this point, we may find the ninth inter costal space clearly dull, from fluid. In such cases the area of pulmonary reso nance on the sound side should be care fully noted as a comparative guide.
The diaphragm has been shown to be higher, if possible, in some cases of em pyema, on the affected side. than on the sound side. The organ will rise when the compression is removed; hence the advice of Stokes to go above the eighth interspace in cases of resection, incision, or puncture.
The sixth interspace in the midaxil lary line or the eighth in the posterior axillary line near the border of the latis simus dorsi muscle and at the angle or point of the scapula is the point of se lection of F. S. Dennis. The advisability of the three operations (thoracentesis, thortmotomy, thoracoplasty) depends upon the age of the patient, the charac ter of the fluid, and especially, in the latter, upon the fact that it may be a life-saving operation. (Roswell Park.) IiccfstoY.—It is advisable to have all in readiness in cases where empyema is suspected, and an exploratory puncture or aspiration is made, to incise at this point should pus be found to exist.