Extracted from the 
TRANSACTIONS OF THE COLLEGE OF PHYSICIANS OF 
PHILADELPHIA. 
THIRD SERIES, VOLUME IX. A CASE 
OF 
EMPYEMA CAUSING SECONDARY ABSCESS IN 
THE PELVIS AND TERMINATING IN 
SPONTANEOUS DISCHARGE 
AT THE UMBILICUS. 
By 
ARTHUR V. MEIGS, M.D , 
PHYSICIAN TO THE PENNSYLVANIA HOSPITAL AND TO THE CHILDREN'S 
HOSPITAL. 
[Read May 4, 1887.] 
The case of empyema, the history of which I shall 
relate, has seemed to me to be worthy of being recorded, 
as it terminated in a manner which I believe to be 
unique. 
Bridget / an Irish woman, thirty years of age, and a widow, 
was admitted to the Pennsylvania Hospital April 27,1885. She had 
had three children, and there could be no history obtained of any 
hereditary disease in her family. There was reason to think that she 
had been somewhat addicted to drink, but she worked hard as a 
laundress. She was perfectly well until December, 1881, when she 
said she contracted a severe cold, but took no care of herself and 
continued to work for three weeks, at the end of which time she was 
seized with such violent pain in the left side that she was obliged to 
1 The history is from notes taken by Charles Baum, M.D. 136 
MEIGS, 
go to bed. She had fever and dyspnoea with cough and some expec- 
toration, and was admitted to the hospital January 24, 1882, when 
a diagnosis of pleurisy was made, and the following note taken: 
" Left chest, dulness on percussion both anteriorly and posteriorly, 
which is not altered by change of position. Vocal fremitus absent. 
Respiratory sounds blowing and distant. In right, sibilant rales. 
Heart's impulse is about one and a half inches to the right of the 
sternum and in the fourth interspace." January 25th twenty-eight 
ounces of serous fluid were removed from the left pleural cavity with 
the aspirator. January 26th twenty-four ounces of serum removed. 
February 21st there was oedema of the left side of the chest, of the 
abdominal walls, and of the feet. March 16th forty ounces of pus 
were removed by the aspirator, and on March 25th an opening was 
made into the left pleural cavity and a drainage-tube introduced. 
During all this time the patient was under the care of Dr. Hutchin- 
son. A large amount of pus came from the opening and the woman 
improved, and July 3, 1882, she was discharged from the hospital 
cured. 
Within ten days after leaving the hospital she was able to resume 
her work, and continued well until April 14, 1885, when she was 
seized with cramp in the abdomen, which became slightly swollen, 
and she had dyspnoea. The symptoms at this time seem to have 
been referred mainly to the abdomen ; but as at the end of two weeks 
the dyspnoea continued to increase she came to the hospital, and was 
admitted April 27, 1885. When admitted, she did not complain of 
pain, but was very weak and the abdomen was a good deal swollen. 
The notes of the condition at this time are not very satisfactory, but 
it is said that there were present the signs of fluid in the right pleural 
cavity, and that after a few days a swelling appeared at the umbilicus, 
which ruptured and a large quantity of pus escaped. After this the 
dulness on percussion over the lower half of the right side of the 
chest disappeared, and the respiratory sounds could be heard over 
the formerly dull area. 
August 6th I made the following note, having taken charge of the 
ward August 1st: Chest posteriorly, the left side is much smaller 
than the right, and the interspaces cannot be distinguished, the ribs 
being pressed closely together. Anteriorly, the left side is quite as EMPYEMA. 
137 
wide as the right, but is flattened antero-posteriorly and the lower 
ribs are pressed closely together, although the upper ones are not at 
all so. Percussion posteriorly : at the left apex the resonance is 
slightly tympanitic; at the middle portion it is hyper-resonant, and 
at the base somewhat impaired. On the right side there is increas- 
ing dulness from apex to base, where there is flatness. Auscultation 
at the apices posteriorly shows the respiratory sounds to be fairly 
good, although somewhat disposed to be harsh on the right; at the 
middle portions the sounds are good on left and feeble on right side; 
at the bases there is entire absence of respiratory sounds. Vocal 
fremitus and resonance are absent at both bases, weak at middle por- 
tion on left, and equally good on both sides at the apices. Anteriorly 
the percussion note is clear, and the respiratory sounds are nearly 
natural at the left and very harsh at the right apex. The cardiac 
sounds are natural, being merely loud-this probably due to the 
extreme thinness of the chest walls. The apex of the heart is pushed 
somewhat upward and outward. 
The patient is very anaemic and much emaciated, and has had 
irregular fever since she has been in the hospital, which continues 
now. There is quite a large amount of offensive sanious pus escap- 
ing from a small opening at the umbilicus. She is able to sit up in 
a chair during part of each day, but complains much of pain in the 
right loin. Her treatment has consisted principally of tonics-iron, 
quinine, etc. 
Up to this time no doubt had ever been suggested with regard to 
the diagnosis, the case being considered as one of right-sided empyema 
which had dissected downward and discharged itself at the umbilicus. 
It struck me that the condition was a very unusual one, and that 
whatever might be the case, one thing was positive, the pus had not 
a sufficiently free outlet. I therefore asked Dr. J. M. Fox, who was 
at the time in charge of the surgical ward, to examine the patient 
with me to decide whether any surgical measure could be instituted 
for her relief. On August 11th an examination was made, and it 
was found that a probe entered at the opening at the umbilicus could 
only be made to pass downward toward the pubes, to which it nearly 
reached without any pressure being made. It was impossible to 138 
MEIGS, 
make the probe pass toward the chest or either side, the only opening 
being the one which went directly downward. 
Vaginal examination revealed that the uterus was somewhat pro- 
lapsed the os being only about two inches within the vulva. The body 
of the uterus was held firmly in one position by adhesions, the cervix 
alone being movable, and there was great induration of the tissues 
above Douglas's cul-de-sac. 
As the patient was evidently sinking fast and had not many 
days to live, unless something was done for her relief, and as Dr. 
Fox was in favor of some operative measure being attempted to give 
the pus a free outlet; and as it was suggested that the origin of all 
the disease, which so evidently existed in the lower part of the 
abdomen and in the pelvis, might be an abscess which had had its 
starting-point in the cellular tissue around the uterus, in which case 
certainly an operation was urgently called for, we decided to make 
an exploratory incision above the pubes, and then, if it seemed expe- 
dient, to introduce a drainage-tube and bring it out through the 
vagina, thus giving a free outlet to the pus. 
August 13th a director was introduced at the umbilical opening, 
and passed down toward the pubes, and its lower end was then cut 
down upon. A large cavity containing pus being found somewhat 
to the left of the median line, the incision was carefully continued 
until the upper end of the vagina was reached, and a drainage tube 
was passed in at the abdominal opening, and brought out through 
the vagina. The tissue between the cavity found to the left of the 
median line in the lower part of the abdomen, and in the pelvis 
and the vagina, was thin, and there was very little cutting necessary. 
The patient never reacted after the operation, but died August 15th. 
On the day of her death an examination of the urine showed that it 
contained a large amount of albumen, pus corpuscles, and granular 
and hyaline tube casts. 
Post-mortem examination showed the following conditions : Heart 
healthy in all respects, except that there were some very minute 
vegetations upon the auricular aspect of the mitral valve. Lungs : 
the left was somewhat larger than the right, and was adherent 
throughout, the adhesions being old and very firm, and the left 
thoracic cavity was much contracted. The right lung also was 139 
EMPYEMA. 
firmly adherent throughout, and its surface was clean, and every- 
where free from pus, there being none between it and the chest walls 
or at its base. The tissue of both lungs seemed natural, except that 
they had both been much compressed. The upper half of the right 
pleural cavity was much reduced in size, partly owing to the general 
contraction of the chest, but still more to the fact that the liver, 
which was much enlarged, was situated unusually high within the 
cage of the chest, and was held immovable by adhesions between its 
surface and the contiguous inner walls of the thorax. Between the 
posterior and lateral surface of the liver and the thoracic walls, there 
was a cavity containing about half a pint of thick creamy pus. 
This cavity had been connected with a flattened canal, whose calibre 
was probably equal to a circle three-quarters of an inch in diameter, 
which began at the posterior portion of the liver, and had channelled 
its way down in the abdominal walls, but always outside the peri- 
toneal cavity, until finally it terminated at a point opposite the left 
obturator foramen. Its course was from the back, where it had its 
origin, first toward the right, so that when it reached a point about 
on a level with the umbilicus it was in the right flank, thence it 
passed forward, being within the anterior wall of the abdomen and 
crossed just above the pubes, terminating, as already stated, in the 
cavity oposite the left obturator foramen. From this sac the pus 
had found its way, previous to the operative interference, upward in 
the anterior wall of the abdomen, and had discharged itself at the 
opening at the umbilicus. At the time the post-mortem examina- 
tion was made the upper cavity was shut off just at the lower 
border of the liver, from the pus channel through which it had 
evidently formerly discharged itself. The pus within this cavity 
was thick and creamy, and quite different from the offensive sanious 
liquid found everywhere. It had penetrated below, so it seemed likely 
the original abscess had been, for some days at least before death, 
shut off, so that no discharge from it had taken place. The relations 
of the diaphragm to this upper pus chamber could not be satisfac- 
torily made out at the post-mortem examination; a large section 
therefore of a portion of the upper surface of the liver that was 
within the cavity, and a portion of the thoracic wall containing 
pieces of three ribs which was directly opposite the piece taken from 140 
MEIGS, 
the liver, were removed for more careful dissection and microscopic 
examination, to determine whether the diaphragm was adherent to 
the upper surface of the liver or to the thoracic wall, and thus 
decide whether the abscess was properly within the thoracic or 
abdominal cavity, which fact the primary dissection did not satisfac- 
torily determine. 
The drainage tube, of course, was seen to lie partially in the 
peritoneal cavity, the posterior wall (which was very thin) of the 
abscess occupying the lower part of the abdomen and upper part of 
the pelvic cavity, having been broken through in the course of the 
operation. The portion of the tube, therefore, between this posterior 
wall of the abscess cavity, and the place where it passed into the 
vagina, was within the peritoneal sac. 
There were extensive peritoneal adhesions, both old and fresh, and 
a good deal of fresh plastic lymph scattered here and there, upon 
the peritoneal surface. The uterus and ovaries were bound down 
by numerous firm adhesions. 
A portion of kidney was reserved for microscopic examination, 
but its condition was not satisfactorily determined macroscopically. 
Dr. de Schweinitz, to whom I sent the specimens already men- 
tioned as reserved for more minute examination, made the following 
report: 
1. Piece of liver, on the surface of which was a grayish-white 
membrane, three-sixteenths of an inch thick. Transverse sections, 
including this membrane, were cut, stained, and examined: The 
most external portion of the membrane is composed of rows of 
deeply stained, young cells (leucocytes); beneath this is a stratum of 
spindle and young connective-tissue cells; and, finally, there is a 
layer of well formed, fibrous connective tissue. The structure pre- 
sents the characteristics of a pyogenic membrane. Beneath it the 
liver cells are swollen, granular, and the nuclei in active prolifera- 
tion. Still deeper the same granular appearance is noted, also more 
or less pigmentation and separation of the liver cells by young, 
round cells, and in the intralobular veins and lobular capillaries plugs 
of micrococci. The process is a parenchymatous inflammation, 
probably septic in origin. 
2. Portion of three ribs, to the inner surface of which was attached EMPYEMA. 
141 
a dense, corrugated membrane, and to its upper end some pieces of 
lung tissue were intimately adherent. Sections from various por- 
tions of this membrane exhibit a variety of tissues. The free surface 
is often covered with a layer of granulation-like cells; beneath this, 
spindle cells and young connective tissue, and still deeper, denser 
fibrous tissue. Numerous bloodvessels permeate the sections ; their 
walls are often thickened, and in many instances the lumen entirely 
blocked up by an overgrowth, apparently of the middle and inner 
tunics. There are areas of distended lymph spaces, the endothelial 
lining of which shows active proliferation. The lung tissue, which 
is adherent to the upper portion, shows in the alveolar walls a young 
cell activity ; the alveolar spaces are for the most part empty, but are 
here and there partially filled with proliferated cells. This portion 
of the membrane presents the characteristics of thickened pleura or 
pleuritic adhesions. The lower portion of the membrane is much 
thicker, and while it shows much the same structure, is chiefly com- 
posed of a dense, well felted connective tissue. 
3. A small piece of kidney. Sections including the cortical and 
medullary portions were made. The epithelia of the convoluted 
tubules is in all stages of fatty degeneration, from a mere cloudy 
swelling of the cells, their nuclei being still distinguishable, to a 
complete fatty degeneration, and the production of a granular 
detritus. Passing to the descending branches of the tubules, fewer 
changes in the cells are noted, but the tubes are partially filled with 
a desquamative catarrh. The renal glomeruli also show swelling, 
and proliferative activity in their lining cells. The process is a 
parenchymatous inflammation. 
This examination has failed to demonstrate the presence of 
muscular tissue on either the membrane, upon the liver surface, or 
in the one lining the inner surface of the ribs, and hence has not 
positively revealed the situation of the diaphragm. It seems, how- 
ever, to have definitely shown that the membrane upon the liver 
neither is, nor has been, diaphragm ; and hence makes it probable 
that the thickened portion of the tissue covering the inner surface of 
the ribs may have belonged to this structure, although there is no 
muscular tissue present to prove this. 142 
MEIGS, 
From every point of view this case was one of unusual 
interest. The history of the first attack of empyema 
and its cure under the judicious management of Dr. 
Hutchinson, is complete. With regard to the second 
and fatal attack, the history is sufficiently clear to allow 
of the sequence of events being satisfactorily followed. 
When I took charge of the case upon August 1st, the 
complication of symptoms was very great-there was 
the history of the first attack of empyema, and its cure 
by operative procedure, then the history, equally clear, 
apparently, of the second attack, and last, the fact that 
a large amount of pus was being constantly discharged 
from the opening at the umbilicus. The fact that in the 
history it was distinctly stated that a diminution of the 
dulness upon percussion over the lower posterior part 
of the right lung occurred coincidently with the dis- 
charge at the umbilicus, and that the respiratory sounds 
which had been distinctly impaired over the same region 
improved in quality, amounted to convincing evidence 
that there had been an empyema, and that some of the 
pus, at least, had escaped. Some of those who saw the 
patient at this time, thought the diagnosis of a second 
empyema was a mistake, and that the case was one 
simply of pelvic abscess. My opinion, however, was 
always fixed that there had been a second attack of 
empyema, and that however difficult it might be to 
reconcile the then existing symptoms with this hypothe- 
sis, it must be the correct one, for how otherwise could 
the physical evidences that there was fluid in the plural 
sac have changed so soon as the discharge at the 
umbilicus took place, and such was plainly and distinctly 
stated to have been the fact in the notes taken at the 
time. 143 
EMPYEMA. 
Dr. Fox was asked to see the patient because I had 
decided in my own mind that the pus had not a free 
outlet; when, therefore, his examination demonstrated 
that there must be a collection of pus in the lower part 
of the abdomen, or in the pelvis, it was easy for us to 
come to the conclusion that the woman's only chance of 
life lay in some operative procedure. To decide, how- 
ever, exactly what should be done, raised the question 
of the origin of the condition, and our conclusion was, 
that it would be best to etherize the patient, cut down 
upon the collection of pus, and then be guided by 
what was found, whether to stop at that point or to 
go on and pass a drainage tube through to the vagina. 
The mistake we made in opening the abdominal cavity 
was a natural one, and made no difference in the ulti- 
mate residt, for the woman was sinking fast before 
the operation was attempted, and it was only done be- 
cause it was thought right to give the patient what 
appeared to be the only possible chance of life. It 
would have been better to stop as soon as the pelvic 
collection of pus was reached, and we should have 
contented ourselves with letting it discharge ante- 
riorly, but the relation of parts was so altered by the 
disease, and the posterior wall of the abscess was so 
thin, as was subsequently seen at the post-mortem 
examination, and the tissues around the uterus were so 
indurated, that Dr. Fox was deceived into thinking that 
the collection had certainly had its origin in some 
inflammation in the cellular tissue around the uterus, in 
which case the only plan which would offer the woman 
any chance, lay in free drainage through the vagina. 
Meantime, the whole region was bathed in such quanti- 
ties of pus, that the operation had to be carried on 144 
MEIGS, 
depending almost entirely upon the sense of touch, and 
it was only at the post-mortem examination that it was 
discovered what had actually been done. It is not sur- 
prising that the mistake was made, as the complication 
of conditions was so great that even at the post-mortem 
examination it was only with the greatest difficulty that 
the true state of affairs was plainly made out. 
The case is complete in every respect, except that the 
post-mortem examination did not establish absolutely 
whether the abscess had its origin above the diaphragm, 
and was, therefore, an empyema, or below, in which 
case it must have been due to some perihepatic inflamma- 
tion. I regret extremely that at the time the examination 
was made I was obliged to go away before it was com- 
pleted, for certainly a more careful dissection would 
have shown accurately the position of the diaphragm. 
Although the position of the diaphragm was not with 
absolute certainty determined, it seems fair to assume, 
that the disease originated as a pleurisy and empyema, 
for all the indications, both from the history of the case 
and the post-mortem results, point toward that having 
been the mode of origin. The probability is, that the 
pieces taken from the wall of the thorax and upper 
surface of the liver for microscopic examination, and to 
the surface of one of which the diaphragm or its remains 
must have adhered, included a part of its tendinous 
centre, and for that reason the microscopic examination 
failed to show the presence of any muscular tissue. 
The manner in which the pus dissected in this case, 
and the direction it took, were those which, from an 
anatomical standpoint, would have been said to be 
almost impossible. The result simply shows that pus 
may find its way anywhere, and that in its course it is EMPYEMA. 
145 
governed by no laws. It is simply inexplicable why it 
should have travelled in the abdominal wall all the way 
from the back upon the right around at the side across 
the front, and finally produced a secondary large cavity 
in the lower part of the abdomen and pelvis on the left, 
and then have risen upward to discharge itself at the 
umbilicus, when at no time was there anything but a 
very thin layer of tissue between it and the peritoneal 
cavity, and but little between it and its discharging 
externally. The channel down which the pus passed 
from the empyema to the secondary cavity below was 
as distinct and outlined in the abdominal wall as if a 
tube had been passed from the one cavity to the other. 
An examination of such literature as has come within 
my reach has failed to lead me to any account of a case 
similar to the one I have narrated. Jaccoud (Pathologic 
Interne, 1873, tome second, page 142) mentions that an 
empyema has been known to discharge itself like a psoas 
abscess, below the " crural arch." Fraenzel (Ziemssen's 
Cyclopaedia, American edition, vol. iv. page 620) says 
an empyema may discharge "in the region of the navel," 
and again, that if " the pus once reaches the peritoneal 
sac, or gets behind it, we can scarcely exhaust all the 
possible channels it may subsequently take." Fuller 
(On Diseases of the Lungs and Air-Passages, Phila., 
1867, page 179) says : 
"Adhesions give rise to another difficulty in the diagnosis of the 
disease. When the two surfaces of the pleura have become adherent 
at various parts by means of adventitious membrane, the effused 
fluid may be circumscribed, or, in other words, may not be contained 
in the general cavity of the pleura, but in a sac or sacs formed by the 
adventitious membrane." 146 
MEIGS, 
In connection with the subject of pleural inflamma- 
tions in general, it will perhaps not be out of place for 
me to describe several matters of fact which have come 
under my notice in the course of various cases that 
have been in my charge, especially as they have an 
important bearing upon questions of diagnosis and 
treatment. 
In the first place, it has happened more than once that 
the only pain complained of, in cases of pleurisy I have 
attended, has been in the abdomen. Only last summer 
a woman was under my charge in the Pennsylvania 
Hospital, who was brought in by a physician because 
he thought she had obstruction of the bowel, and wished 
to give her the opportunity of having surgical treat- 
ment, of which he thought her in urgent need. When 
I examined her 1 found the abdomen exceedingly tender 
to the touch, and she complained of great pain in one 
lumbar region. At the same time the abdomen was not 
materially swollen, nor was there any of the doughy 
induration which is so characteristic of peritoneal in- 
flammation, and so apt to exist if there is any intestinal 
obstruction, but upon the same side with the lumbar 
pain it was found that there was slight but distinct 
dulness upon percussion over the lower part of the lung 
posteriorly, and decided feebleness of the respiratory 
murmur. By the next day, or next day but one, the 
pain had all disappeared, and the case proved to be one 
of pleurisy with moderate effusion; the patient soon 
made a good recovery. The reason why, in cases of 
pleurisy, occasionally the only pain felt should be situ- 
ated in the abdomen, I have never been able to com- 
prehend, unless the explanation is to be found in a 
statement made by Goodhart (" Cases of Peritonitis," EMPYEMA. 
147 
Lancet, March 5, 1887), in discussing peritonitis. He 
says: 
" One other word about these cases, which always seems worth 
while to insist upon, viz., the frequency with which pleurisy spreads 
from peritonitis and peritonitis from pleurisyI do 
not think the freedom of communication between the serous sacs of 
the peritoneum and pleura is sufficiently well recognized." 
Unless, then, the abdominal pain is due to an irrita- 
tion or even a slight degree of inflammation of the peri- 
toneum, I am unable to offer any explanation for what 
is certainly a not very rare clinical phenomenon. The 
knowledge that such a train of symptoms may arise and 
the explanation be that the patient has an attack of 
pleurisy, has rendered me careful in all cases of severe 
abdominal pain, when I can find no other cause adequate 
for its production, to search carefully for any sign of 
pleuritic inflammation. 
Second, I learned, from what happened in a case of 
which I had charge some years ago, the inexpediency of 
making the opening in cases of empyema that have to 
be operated upon too low down. When I took charge 
of the wards of the Pennsylvania Hospital one season, 
several years ago, I found a man suffering with empyema 
into whose chest a drainage tube had been introduced. 
The tube was at the side in the region beneath the 
axilla, and was passed in, I think, between the seventh 
and eighth ribs and brought out between the ninth and 
tenth, this made it, of course, very near the inferior 
margin of the chest. I found that the drainage through 
and at the side of the tube was not free, and at the same 
time the results of physical examination seemed to show 
that there was a good deal of fluid in the thorax. At 148 
MEIGS, 
no time did the discharge stop, but it did not seem to 
come away as freely as it should have done, and the 
thorax never seemed empty of fluid. The case pro- 
gressed from bad to worse, and some of those who saw 
the patient urged me strongly to make another opening 
lower down so as to give the pus a more free outlet. 
This I could never make up my mind to be advisable, 
feeling that the opening was already low enough, and 
having an instinctive feeling that that was not what was 
needed. At last the man died, and the post-mortem 
examination showed clearly enough what had been the 
matter. At the time of death and at the autopsy, no 
part of the drainage tube was inside the sac of the 
empyema, but that part of it which was under the two 
ribs, around which it had been passed, lay in a sinus. 
When first introduced it had been within the pleural 
sac and had freely drained the pus, but as the amount 
of matter became less, nature, in the endeavor to reduce 
the size of the pus-forming cavity, had approached the 
two walls of the thoracic cavity at the bottom, where it 
is wedge-shaped, with the sharp edge downward, toward 
each other, and had, beginning at the bottom, gradually 
glued them to each other, thus lessening the size of the 
cavity from below upward, until finally, as already said, 
the drainage-tube lay in a sinus entirely below the sac, 
and no longer allowed of the escape of any pus. This 
state of affairs could have existed for only a short time 
before death, for until the last few days there was always 
more pus discharged than could have been formed by 
the small sinus in which the tube was found lying after 
death. The closure, therefore, by agglutination of the 
pleural surfaces of the inner wall of the thorax and that 
covering the diaphragm, must have been a very gradual EMPYEMA. 
149 
one, for, as is evident, two forces were at work, the one, 
the effort of nature to reduce the size of the pus-forming 
sac from the bottom, and the other the tendency of the 
constant pressure of the increasing amount of pus as its 
outlet became less free to stretch this open. The final 
result made an indelible impression upon me in that 
it taught me that if we wish for success in our opera- 
tions for the relief of empyema, we must imitate the 
practice of Nature, who, when she makes an opening 
into an empyema, is careful not to make it too low 
down. The next time I have occasion to perform an 
operation for its relief, I shall pursue the plan which 
has been followed with such excellent results by Dr. 
Nancrede at the Episcopal Hospital in this city, of 
having a large piece of one, or, if necessary, two ribs 
resected with a trephine. 
Third and last, I learned that in dealing with empy- 
ema, if there should be an accumulation of fluid in the 
other pleural cavity, it is much best let alone. I had 
charge, some years ago of a negro, into whose chest I 
introduced a drainage-tube for the relief of empyema 
from which he was suffering. After a little time it 
became evident that liquid was accumulating in the 
other pleural sac, and as his symptoms became rapidly 
more urgent, I determined to attempt to relieve him by 
drawing some fluid from the sac with the aspirator. 
This was done, but instead of affording any relief the 
lung seemed entirely incapable of being expanded, and 
from the moment the operation was done the dyspnoea 
increased until death, in a very few days, terminated his 
sufferings. 150 
MEIGS, EMPYEMA. 
Krause. Das Empyem und seine Handlung. Danzig, 1843. 
Barlow and Addison. Empyema and other Pleuritic Effusions, 
Lancet, 1855, vol. ii. 
G. Rogers. Cases of Empyema, British Med. Journal, 1857. 
Roiirig. Ueber einige Faile von retroperitonalen und extrapleu- 
ralen Abscesse, Deutsche klinik, 1862. 
Wardell. On Empyema, Lancet, 1867. 
Bird, W. Observations on Pleuritic Accumulations, British Med. 
Journal, 1868, vol. i. 
Sciiotte. Ueber Empyema, Berlin, 1869. 
Jaccoud. Pathologic Interne, vol. ii. p. 142, 1873. 
Fraenzel. Ziemssen's Cyclopaedia, American ed., vol. iv. p. 620. 
Fuller. On Diseases of the Lungs and Air-passages. Phila., 
1867, page 179. 
Flint. On the Respiratory Organs. 
Goodhart. Cases of Peritonitis, Lancet, March 5, 1887. 
BIBLIOGRAPHY.