An early treatment and rest in bed with a liquid diet are the measures
to be employed at the beginning of the attack. Pay particular attention
to any primary disease and to the general health. Rarely is there any
difficulty in locating certain predisposing causes of the disturbance.
Then often a rib or corresponding vertebra is badly subdislocated
over the seat of the disease. The sympathetic and phrenic nerves
are involved through the intercostal and phrenic nerves. A careful
examination of the side of the affected chest should be made, as there
may be more or less obstruction of the intercostals and the internal
mammary arteries from their branching of the aorta and subclavian
vessels. A dislocation of the first or second rib may affect the
subclavian vessels and their branches markedly; although all the
upper ribs and the thoracic muscles should be examined carefully for
derangements which would affect these blood-vessels and produce an
exudation. Ice-bags upon the chest, as in pneumonia, may be used.
Limiting the movements of the chest with a bandage or adhesive strips
will give considerable relief.
When the effusion has taken place, carefully raising and spreading
the ribs with attention to special points of involvement, will at
times cause absorption of the fluid. The daily amount of liquid food
should be greatly lessened with a view of depleting the blood serum
from various tissues; thus the serum collecting in the pleura, which
is a lymph space, will also be absorbed. Treatment of the bowels,
kidneys and skin, so that they may be rendered active, will aid in the
depletion of the blood serum.
It may be necessary in some cases to aspirate, especially if other
methods fail and if the effusion is large. The points of operation
are in the mid-axillary line at the sixth interspace or at the angle
of the scapula at the eighth interspace. In puncturing, the needle
should be held close to the margin of the upper rib so as to avoid
the intercostal artery. Withdraw the fluid slowly and if faintness is
produced, desist.
Empyema should be treated surgically. Simply tapping is rarely
sufficient. A free incision, as in abscess, and thorough drainage
should be made. Care must be taken that the drainage tube is large
enough.
“In cases of pleurisy the axilla and the inner arm may be tender and
painful; this is due to the pleuritic inflammation being carried by the
way of the ‘nerve of Wrisburg.’
“The pleuritic pain in the costal muscles compels restricted movement
of the ribs and also limits the respiratory function of the diaphragm.
These painful cramps and stitches are independent of the pain arising
alone from the inflamed pleural surface, and the diminution of the
respiratory movements is due to a particularly contractured state
of the muscles of the chest as is demonstrated by the fact that the
patient can not draw a long breath; hence one may reasonably conclude
that nature has so distributed nerves to the pleura as to enable that
serous membrane to control the muscles which create movements of the
adjacent costal surfaces and thus insure its quietude during the stages
of inflammation or repair.” (Ranney).