THORACENTESIS-PUNCTURE OF A SEROUS EFFUSION The removal of the effusion in children is less frequently necessary than in adults, since absorption is more apt to occur early and spon taneously. Otherwise the indications are of the same value. In rare cases puncture becomes in the beginning of the disease a means of pre venting death whenever the effusion by its rapid increase causes dysp tuna, cyanosis, and cardiac weakness; then, again, in very large effu sions which lead to displacement of the heart and severe dyspncea in the average patient, when the effusion has risen to about the level of the third rib anteriorly and the middle of the seapula posteriorly. When ever possible. however. one should wait until the fever has subsided (about the third week), since otherwise the effusion is often rapidly re newed. Finally, paracentesis is also indicated whenever a smaller effu sion Shows no tendency to spontaneous absorption after abatement of the temperature. No fixed rule can be laid down in these cases. If an effusion has existed for a longer period than 0-S weeks, thickening, adhesions. and impeded expansion of the lungs usually result.
Method of Thencture.-1 troear of at least 2 rom. calibre and if possible haling a lateral return flow is selected (as in Fig. 90) attached to the opening of which is a strong rubber tube about three feet in length and filled with a solution of boric acid or sterile water. If the point of puncture is open to choice, about the seventh intercostal space is chosen in the middle or posterior axillary line, under all circum stances at a point where flatness and absence of fremitus are present.
If one is not entirely certain regarding the condition, an explora tory- puncture should be done pre viously. The child is held firmly in the sitting position. Under anti septic preeautions the trocar is quickly introduced for about 2-3 en). above the edge of a rib (the intercostal artery runs behind the lower border of the rib) and the stilet withdrawn. The effusion in recent cases is under absolute pressure and evacuates itself. A sudden interruption of the flow is caused by shreds of fibrin which are pushed back by the blunt needle. In large effusions the evacuation is prolonged by closure of the trocar from time to time, otherwise collapse may take place. Indeed, it is wise in cases of debilitated children
or in large effusions to give coffee or brandy with water before the opera tion. As much of the fluid is evacuated as will flow out spontaneously. In long existing effusions very little or no fluid will flOW out spontaneously because the pressure within the pleural cavity is not sufficient. In these cases the water-filled siphon tube attached to the return opening of the trocar which after closure of the cock of the trocar is led vertically downward into a flask is of service. It itself aspirates slightly. If this is not successful, one of the well-known aspirators, Potain's, etc., is to be brought into SCIVICC.
Instead. an apparatus, as pictured in Fig. 90 by which the aspira tion is done with the mouth, may be inexpensively improvised, and will be just as good as those expensive instruments. If a simple trocar is possessed, the rubber tube, sterilized and filled with water, is pushed over to the single opening of the trocar and the aspirator is then attached. In case of necessity a large piston syringe will suffice. No force what ever should be used in aspirating. A large effusion must not be removed entirely, and at any rate one must desist as soon as violent coughing or weakness occurs or if the effusion becomes bloody. The puncture is closed with a collodion dressing. If paracentesis has not been done dur ing the febiile stage the rest of the effusion usually becomes absorbed spontaneously, otherwise, and also during the existence of the original, additional punctures may become necessary.
Treatment of Empyema.—The sooner the pus is evacuated the more rapidly and easily will recovery take place. Early recognition will often prevent long illness and death. As soon as a pleurisy is recognized as being purulent no time must be lost with expectant treatment, but evacuation of the pus must proceed at once. A short delay is permissible only in cases of small emprma, following pneumonia in which the ex ploratory puncture has yielded only a small amount of pus and the general condition is in a state of improvement, since pneumococcus empyemata of small extent may often become absorbed spontaneously.