THORACENTESIS. 



489 



Fig. 434.— Trocar paracento-injecteur de Keul. 



According to St. Cyr, the proper 

 place for the puncture is between the 

 seventh and eighth sternal ribs, a 

 little above the spur vein, this jDoint 

 permitting the removal of a larger 

 quantity of fluid than any other, with 

 the advantage also of offering a wider 

 space between the ribs, and a dimin- 

 ished thickness in the muscular sub- 

 stance. Unless there are special rea- 

 sons to the contrary, the puncture is 

 made on the right side ; if operating 

 on the left is indicated, care must 

 be taken to avoid injuiing the heart. 

 For this reason the puncture is made 

 between the 

 eighth and ninth 

 ribs, with the 

 point of the in- 

 strument turned 

 backward. The puncture is made with the patient on his feet, 

 and he rarely needs any apparatus of restraint, though it will 

 always be judicious to apply a twitch on his lip. 



St. Cyr describes the operation as follows : " The operator 

 makes an incision with the bistoury, about one inch long, near 

 the anterior border of the eighth rib or of the ninth, if he is on 

 the left side, dividing the skin and superficial muscular layers 

 until he reaches the internal intercostal muscle, which he leaves 

 intact. In piercing the cavity, he holds the trocar with the right 

 hand, guarding against its entering the chest too deeply by keep- 

 ing his fingers sufficiently near the point to gauge and control its 

 depth through the remaining undivided muscle. What remains 

 then is to withdraw the rod from the trocar, and keep the latter 

 in place while the fluid escapes. Any albumino-fibroid clots, 

 which may enter the canula and obstruct the flow of the liqiiid, 

 may be dislodged by introducing a blunt stylet into the tube. 

 When the canula is withdrawn after the escape of a sufficient 

 amount of fluid, the wound is closed with a single pin suture. 



The trocar of Mr. Keul is inserted (Figure 434) in the usual 

 manner, with the nut E closed, and after removing the desired 



