Strapping the affected side of the thorax at once alleviates the intensity of the stabbing pain and prevents coughing by securing immediate rest to the inflamed opposing layers of the pleural membrane. Stout strips of adhesive rubber plaster should be applied to the skin on the sound side of the chest beyond the sternum, and these must be brought round the affected side whilst the patient makes a forcible expiration, the extremity of each strip of plaiter being fastened on the sound side of the spine so as to fix permanently the inflamed half of the thoracic cavity as in a vice. Not only is the pain usually speedily alleviated by this procedure, but rest to the diseased pleural membrane is so completely effected that the subsequent effusion is often rendered scanty and the duration of the attack shortened. Firm bandaging of the entire thorax is inferior to strapping.
Whilst the above measures are being employed the patient should be placed upon the diet suitable for most acute febrile affections. Milk diluted with a plain effervescing water or liquor calcis meets all require ments; farinaceous foods need not be withheld, and soups or beef essences may also be permitted. Whatever advantages may follow the use of a strictly dry diet in the stage of effusion, none will accrue by adopting this system of treatment in the early inflammatory period of the disease, and the same remark applies to the unscientific routine administration of saline purgatives with the view of preventing effusion.
Drugs which control fever heat and cause free elimination of deleterious products by the skin and kidneys may be employed in moderate doses; one of the best routine combinations is the following, the amount of Morphine being determined by the presence of persistent pain, continuous unrest, or incessant coughing: R. Tinct. Aconiti 3j.
Sodii Salicyl. 3ij.
spt. mindereri Liq. Morphice Hyd. 3j. Aquas Camph. ad 5viij.
Fiat mislura. ass. lerlia q. hora.
Where the fever tends to keep high the amount of Salicylate may be doubled, or a dose of 5 grs. Antipyrine every four or six hours may be given, but no real benefit is to be expected from continuous drugging with the coal-tar antipyretics in full doses. Rarely will the pyrexia call for cold sponging or baths. Quinine is not to be relied upon for the reduction of fever, and some on the theory of a rheumatic affinity being present in acute pleuritic, recommend the routine of I5-gr. doses of pure Salicylic Acid administered in cachet form.
When effusion has occurred in mild cases, usually the pain and fever have disappeared, and the above-mentioned drugs should be stopped. In severe cases the fever may, however, continue, and their suspension is equally imperative, since no remedy should be administered which exercises any depressant action upon the overburdened heart in extensive effusions.
The treatment of effusion then collies to be the question of vital impor tance. The tendency of modern practice is to resort to tapping without delay, but this must not be accepted as a routine method for the treatment of all effusions following inflammation of the pleura, as many such when of moderate extent tend to disappear spontaneously or under the influence of medical agencies, especially in children and young subjects.
The physician should therefore pause before immediately resorting to thoracocentesis, when the amount of fluid is small and there is no undue pressure upon the heart or embarrassment of respiration, till he sees that there is no marked tendency towards absorption, since he possesses agents which undoubtedly exercise a considerable power in hastening the process.
Blistering is the most reliable of these agents, and is often successful in removing sluggish accumulations of fluid when these are of moderate amount. One large cantharidin plaster (4 by 6 inches) may be applied to the thoracic wall and left in situ for 8 hours till thorough vesication takes place, or the latter result may be hastened by the application of a warm poultice after a shorter exposure of the skin to the vesicant. A better plan, however, is to employ several small blisters to different parts of the chest wall for a period of three hours each. These flying blisters should be of about the size of a crown-piece, and 3 or 4 of them may be applied at the same time at different spots, though a better plan is to use only one of larger dimensions (3 by 3 inches). This should be placed over the lower part of the affected side near to the diaphragmatic attachment for about 3 hours; on its removal the same blister is next applied higher up for 3 or 4 hours more, after which it should be attached for 6 or 8 hours about the upper level of the fluid.
The effect of this treatment is often so marked that the writer has satisfied himself that the stimulating effect upon absorption cannot be entirely explained by the theory of counter-irritation. The cantharidin of the plaster appears to exercise some specific action over the lymphatic cells, or else to possess a lethal effect upon the cocci or bacilli which are invariably present in the effused fluid. An effect akin to this is often observed when a hypodermic needle has been employed in exploratory puncture and only a small quantity of fluid has been extracted.