THE TREATMENT 
OF 
EMPYEMA 
BY 
VALVULAR DRAINAGE. THE TREATMENT 
OF 
EMPYEMA 
BY 
VALVULAR DRAINAGE. 
A Paper Read Before the Medical Society of the State cf New York, February h 1220, 
By A. M. Phelps, M. D., 3hateaugajt<fc^ 
Published in the Medical Record April 3, and in the Transactions of the 
State Medical Society for 1880. 
SYRACUSE, N. Y. 
STANDARD STEAM BOOK AND JOB PRINTING HOUSE. 
1880. ins MIIMT f EM 81 (Mil DIMM. 
By A. M. Phelps, M. D., Chateaugay, N. Y. 
Ill examining authors, and reading the different plans of 
treatment recommended in empyema—varying from the simple 
puncture with the trocar and canula to the radical operation of the 
Germans—one is as much amused as when gazing upon the body 
of the beautiful and changeable chameleon. Like the chameleon 
it seems to assume the color of the soil upon which it derives its 
nourishment. The Germans recommend one plan of treatment, 
the French another, the English another, and the Americans still 
another; but all seem to agree upon one point, and that is, that 
thorough drainage and ablution are the first principles, the “ sine 
qua non” of all treatment. 
I believe these are but auxiliaries in treatment. 
But lying away down underneath all this, is a first principle— 
the corner-stone upon which all prognosis and treatment should be 
based. I allude to the speedy obliteration of the pleural cavity by 
the greatest possible expansion of the lung. This principle, and this 
alone, should be the one upon which all operative interference 
should be based. 
The cure of an empyema is not affected by washing or evacuat- 
ing the pusher se, but by the expansion of the lung and falling in 
of the chest-wall—one or both. The adhering together of the 
pleura? brings about the object at which we aim—viz., the 
obliteration of the pus-secreting cavity. 
This process can never take place if pus is allowed to accumu- 
late or decompose in the pleural cavity, and only very imperfectly 4 
if air is permitted to freely pass in and out the drainage-tube during 
the act of respiration. When the lung ceases to expand sufficiently 
to perfectly till the pleural cavity, adhesions form between the 
pleural surfaces. What is the result of this? A large pus-secret- 
ing cavity; and unless kind nature bends in the chest-wall to 
obliterate this cavity that should have been tilled by the lung, we 
find our patients dying from exhaustion, or going through life 
with a thoracic fistula. The lung, in this collapsed condition, is 
very prone to caseous pneumonia, and a large per cent, of cases 
die from this secondary malady, even after the empyema is entirely 
cured. 
The question that should arise in every case of empyema is not, 
How shall I evacuate and wash this pleural cavity? but, How 
shall I speedily obliterate it? The principles of treatment involved 
in the above are— 
1st. Evacuation of the pleural cavity as speedily and judi- 
ciously as possible, thus preventing the permanent collapse of the 
lung. 
2d. Thorough ablution and disinfection. 
3d. Strapping the chest with strips of adhesive plaster over the 
alfected side, following the direction of the intercostal muscles, 
thus keeping the chest quiet,'and allowing the pleural surfaces to 
unite. 
4th. The introduction of a valved drainage-tube. 
This keeps up pneumatic pressure upon the lung, by preventing 
air from entering the pleural cavity, and acting as a brace under- 
neath the collapsed lung. 
A large per cent, of these cavities are obliterated, and the 
patient cured by repeated aspiration, incases where it is admissible. 
It should be performed often enough to allow the pleural surfaces 
to come in contact and not be disturbed by pressure. If the pus 
is fetid, warm carbolized water, one part to eighty, should be 
injected, and in quantities not so large as to make pressure suffi- 
cient to tear up adhesions, and all to be aspirated before the needle 
is withdrawn. 
The aspirator and needle, which is my modification of Potani’s, 
will be found to be the most convenient form of aspirator for 
washing and evacuating these abscesses, and for general use. It 
has a third tube with which to empty and fill the receiver, thus 
avoiding the necessity of removing the screw-cap; also the fluid- 5 
tube extends to the bottom of the receiver. By this we *can 
inject a cavity without inverting the receiver. 
Fig. i. 
DESCRIPTION OF ASPIRATOR. 
When an aspiration is to be made—the stop-cocks L and J—should be 
closed, the pump attached to the tubing (D) at the end designated with the 
backward pointing arrow—showing that through it the air passes into the 
pump. The pump upon being worked will produce a vacuum in the 
receiver (F). When this is achieved the stop-cock (II) should and 
(L) opened after the needle has been introduced. As soon as the bottle is 
tilled it can be emptied by attaching the pump at its end (B), closing the 
stop-cock (L) and opening (J and U). tJpon working the pump the contents 
of the receiver will pass out through (P). By reversing this procedure an 
injection can be made without disturbing the screw cap (G) of the receiver; 
the reservoir being filled through (P) and emptied through (K) into the 
abscess. The needle is a combination of principles, some of which are found 
in other needles. It consists of three parts as seen in tig. 2. The part (7) 
is slid over and (O) slid into the canula (8) the aspirator being attached to 
the lateral tube (9)—(7) is the cutting needle furnished with a rubber pack- 
ing at (5), being shorter than (8) after its introduction (8) is pushed forward 
through it and the joint is protected. The obturator is to dislodge obstruc- 
tion in the needle during aspiration and passes through a tight rubber 
packing at (4). During aspiration it is drawn out beyond the lateral tube 
(9). Codman & Shurtletf of Boston, manufacture a needle with the same 
obturator, but the needle is introduced by means of an ordinary trocar. 
The needle attached to the tube (K) shows it ready for the operation. In 
aspirating pus and effusion loaded with flakes of fibrin I have not been 
disappointed in its use. 
The needle has a movable point, with a screw packing, which 
prevents air from entering the cavity, and also an obturator to 6 
dislodge any obstruction during aspiration. This instrument, and 
the valve drainage-tube, were made for me by J. Reynders & Co., 
New York, to whom I have presented the models. 
The above cut and description will furnish an idea of its 
mechanism. 
A very valuable and interesting history of aspiration can be 
found in Gouley’s aide work upon Diseases of the Urinary Organs. 
In cases not cured by repeated aspirations, the “radical opera- 
tion ” of the Germans, or free incision into the pleural cavity 
between the fifth and sixth rib in the axillary line, has become a 
favorite one with many of our most eminent surgeons. 
While this operation possesses the merit of thoroughly evacuat- 
ing and cleansing the pleural cavity, it accomplishes nothing 
toward the obliteration of the cavity by the expansion of the lung. 
Pneumatic pressure is taken off the lung by the air entering the 
pleural cavity. Plugging the drainage-tubes does not help matters, 
and it certainly prevents perfect drainage. 
Then the operation punishes the patient more than is necessary 
to accomplish the end desired, and he almost always recovers with 
more or less deformity, owing to the non-expansion of the lung. 
Fraentzell reports five recoveries in eleven cases. Moutard 
Martin reports five recoveries, seven deaths, and five fistuhis in 
seventeen cases (Ziemssen). 
Caseous pneumonia was found in a majority of the cases upon 
post-mortem. This was probably due to the collapsed condition of 
the lung. If the valvular drainage had been instituted, pneumatic 
pressure kept up, and the lung capable of expansion, the per cent- 
age of deaths might possibly have been diminished. 
Chassaignac devised an operation which consisted in making two 
openings into the chest-wall, one in the sixth intercostal space, the 
other in the fourth inter-space, 51 to 76 mm. (two or three inches) 
anterior to the first, and two ribs above. A perforated rubber 
drainage-tube was passed through the pleural cavity between the 
two, and tied together upon the outside of the chest. This is a 
favorite method with some of the English surgeons, and is highly 
recommended by Dr. Hingston, of Montreal, P. Q. He furnishes 
better statistics from it than the Germans from the “radical opera- 
tion.” This operation makes no application of the first principle, 
and from the fact that a large per centage of cases are discharged 
with thoracic fistulas, owing often to the accumulation of pus in 7 
the posterior cul-de-sac below the drainage-tube, it seems as if some 
more perfect means should be devised. For labors in operating 
and furnishing to the world statistics of operations which have been 
verified and proven true by the operators in almost every country 
on the face of the earth, and which have almost completely rev- 
olutionized the treatment of purulent effusions, the profession owes 
its deepest debt of gratitude, not to Germany, France or England, 
but to the United States, in the person of Dr. Henry I. Bowditch, 
of Boston, Mass. He was the man who first introduced into prac- 
tice capillary trocars attached to an exhaust syringe, and taught 
and proved that better results could be obtained in empyema from 
a simple puncture with a trocar and canula, and a soft rubber 
drainage-tube in the ninth interspace in the back, than from any 
other operation up to 1878. 
The operation that appears to evacuate and cleanse the cavity 
most perfectly with the least punishment to the patient, was first 
performed by Drs. Baker and Southy, in Guy’s Hospital, England, 
and reported in the January number of the London Lancet for 
1878. They made two openings into the pleural cavity ; one low 
down upon the diaphragm in front ; the other between the ninth 
and tenth ribs in the back, as recommended by Bowditch. Rub- 
ber tubes were inserted into each opening, and the cavity thor- 
oughly washed out by means of a rubber tube and funnel, the 
current of water passing from the front to the back opening. The 
patients recovered with but little deformity of the chest. This 
procedure drains and washes the pleural cavity thoroughly with as 
little inconvenience to the patient as possible, but the value of 
pneumatic pressure is completely lost sight of. 
In the method which I propose, the greatest possible advantage 
is taken of this pneumatic pressure, by allowing no air whatever to 
enter from the outside during the whole time of treatment. 
To accomplish this, two openings are made into the pleural cav- 
ity as recommended by Baker and Southy, and then I introduce 
into the posterior opening a tube which I made for the purpose, and 
which is supplied by a valve opening outward. This tube is made 
of silver, of two sizes, according to the age of the patient, is fenes- 
trated at its extremity, and is introduced by means of a trocar. 
Before penetrating the chest-wall the trocar is made to pass 
through a rubber plate (fig. 4 D) which is applied to the outside 
of the chest, prevents air from entering around the tube, and, 8 
being held in place by adhesive straps (fig. 4 G), keeps the tube 
in position. The valve is prevented from opening too far by a 
hook at the extremity of the tube (fig. 3, W). A small india- 
Fie. 3.-Drainage-tube, trocar, and rubber plate : S, rubber plate perforated by drain- 
age-tube T; U, valve open ; X, drainage-tube ; T, opening in same; Z, trocar. Below, 
tube is shown with valve closed. 
rubber bag envelops the extremity of the tube and serves as a 
receptacle for the pus. This bag is easily cleansed by means of a 
stop-cock. M, in its lower extremity. If the discharge is very pro- 
fuse, the pus ipay be drained through the rubber sac into a bottle 
carried in the inside lining of the vest. The tube should be intro- 
duced last, and as the pus escapes the same quantity of water 
should enter through the anterior tube. By this procedure the 
cavity will he more thoroughly washed, and no air will enter it. 
The point selected should be the ninth interspace in the back. 
The anterior tube is introduced low enough to rest upon the 
diaphragm, and thus avoid the pressure upon it by the expanding 
lung. To do this, the pleural cavity should be explored with a 
hypodermic needle, to ascertain the attachment of the diaphragm 
to the chest-wall. The point selected should be upon a line drawn 
downward about 37 mm. (one and a half inches) external to the 
nipple upon the right side, in the sixth interspace if possible, 
taking care not to wound the liver and diaphragm, and 51 mm. 
(two inches) oxternal to the nipple in the sixth interspace upon the 
left side, taking care not to wound the pericardium or diaphragm. 
■ If, upon hypodermic exploration, pus is drawn oft'at the points 
designated, a large trocar and canula should be plunged into 
the pleural cavity in front, and while the pus is escaping a 
soft rubber-tube, 152 mm. (six inches) in length, is passed 
through the canula, penetrating the pleural cavity 25 mm. (one 
inch), when the canula is removed. The rubber tube should now 
be plugged, to arrest the further escape of the pus until the poste- 9 
rior tube is introduced. With a needle pass a thread through the 
rubber tube close to the chest-wall and make it tast to the chest by 
means of adhesive straps (C). This will prevent the tube from 
slipping in or out. 
FIG. 4. * 
When both tubes are introduced, carbolized water may be intro- 
duced through the anterior one by means of a funnel and long 
rubber tube B as fast as the pus escapes from the posterior tube, 
and the cavity can be thoroughly washed without the danger of 
any air entering, and with the advantage of draining from the 
lowermost parts of the suppurating sac. 
This process should be kept up till the cavity is thoroughly 
cleansed, indicated by the water escaping unchanged. After 
the cavity is perfectly cleansed, the long rubber tube and funnel 
is removed, and the anterior tube A is plugged with a piece of 
wood. The valve H, of the drainage-tube, is now dropped to its 
place and made fast by the hook (see W, tig 3), and the rubber 
bag E (a rubber condom, with a puckering string of rubber, will 
answer the purpose) is placed over the end of the drainage-tube F, 
and the lower end made fast to the chest by strips of adhesive 
plaster, laid on as indicated in the cut. 
This rubber bag can be removed, cleansed, and disinfected, as 
* Cut from Medical Record. 10 
often as occasion may require. If the lung is incapable of 
rapid expansion, before dropping the valve II to its place and 
attaching the rubber bag allow all the fluid to escape from the 
pleural cavity, and air to enter it, as it will not give the patient so 
much distress as the weight of the fluid upon the diaphragm; then 
lay the patient in a position so that the drainage-tube will be at 
the highest point, to facilitate the air rising to it, drop the valve H 
to its place, and direct the patient to make a few forced expiratory 
efforts, when the excess of air will rush out of the cavity, and the 
valve preventing its entrance upon inspiration, pneumatic pressure 
is increased by the calibre of the pleural capacity being diminished, 
and the lung, if it is capable of doing so, will expand rapidly. The 
rubber bag should now be attached as described above. The patient 
should lie upon his back during the washing. The adhesive straps 
K should be so adjusted as to prevent all pulling upon the drain- 
age-tube. The washing should be repeated as often as the tempera- 
ture rises from the accumulation of pus. The valve and tube and 
rubber plate should be carefully cleaned as often as they become 
unclean, and the valve kept in a good working condition. If the 
tube should be too long it can be removed, and with an ordinary 
tile and a pair of shears cut to the desired length. It should lie 
tight against the rubber plate to prevent articles of -lothing from 
coming in contact with it, and penetrate the pleural cavity about 
half an inch, thus avoiding the irritating effect of a long drainage- 
tube, which is unnecessary. The piece cut from the tube should 
be put upon the trocar; this will keep the point of the trocar at its 
proper place, otherwise it would be too long for the tube. Flakes 
of fibrin obstructing the drainage-tube at any time should be moved 
aside with a stylet or a perforated catheter. If the anterior tube 
becomes obstructed by the lung expanding down upon it, a small 
catheter can be passed through the valved drainage-tube to the 
anterior chest-wall, and the rubber tube and funnel attached to it. 
By this means a current of water is conducted to the front, and the 
cavity is perfectly cleansed by allowing it to escape through the 
valved drainage-tube. Baker and Southy recommended carbolized 
water; temp. 100° F., one part to eighty; also Condy’s fluid, and— 
Grams. 
ft. Acidi salicylici - - 3 i. 4 
Alcoholis - - - l iv. 128 
Aquae § xxviii. . -896 — 
M. 11 
I have used each of these, and have no preference. They each 
act by disinfecting or preventing fermentation. Strong injections 
should be condemned. 
The cure is effected by the pleurae coming in contact and uniting, 
thus obliterating the pus-secreting cavity. Washing should be sus- 
pended when the discharge ceases to be fetid, and the pus healthy. 
When the lung is incapable of expansion—ceases to expand, or has 
fully expanded—the whole side of the chest should be surrounded 
with strips of adhesive plaster, laid on in the direction of the inter- 
costal muscles. This will keep the side at rest, and favor union of 
the pleural surfaces. 
Deformity of the thorax will depend upon the expansibility of 
the lung. If it is incapable of expansion, a large cavity which 
should be tilled by lung, will have to be obliterated by the falling 
in of the chest-wall. To facilitate this process portions of rib 
should be resected, when the health of the patient will admit of it; 
but if the lung is capable of perfect expansion, and the cavity is 
kept free from pus and disinfected, and the valved drainage-tube 
kept in good working order, patients ought to, and will, recover 
with no deformity, and I am almost inclined to believe that a 
large per centage of cases which have hitherto resulted in perma- 
nent thoracic tistulas will be discharged perfectly cured. 
The following case illustrates the method of treatment: 
Patrick H , farmer, Irish by birth, aged 20 years, was first 
seen by me March 25th, 1878. He had been suffering from pleu- 
ritis for ten days. On physical examination I found a large 
effusion in the left pleural cavity. He had been unable to 
lie down for the previous week. He complained of intense pain 
in the side; was somewhat delirious; tongue dry and fissured; 
temperature 104J°; respiration 30; pulse 130. There was con- 
siderable oedema of the left side, and also of the lower extremities. 
By the introduction of a hypodermic needle between the fifth and 
sixth rib in front, a small quantity of serum, mingled with slightly 
fetid pus, was evacuated. Prescribed diuretics, tonics, and blister. 
The twelfth day, or the third day of my attendance, I explored 
the effusion again lower down in the lateral region, and withdrew 
thickish, fetid pus. I think if I had made my first puncture at 
this point, I should have found pus, as it had evidently gravitated 
to this locality, and the serous portions floated upon it. There had 
been no remission of the symptoms. Temperature 104 pulse 135, 
respiration 28 per minute. 12 
March 28th, with the assistance of Dr. Mott, of Chateaugay, 
I introduced a trocar in the tenth interspace in the back, and 
3.31 liters (three and a half quarts) of thick, decomposed, 
fetid pus, was discharged. The patient felt relieved, hut owing to 
his feeble condition, the operation was deferred until the next day, 
when I found the effusion was as large as the day before. I intro- 
duced a rubber tube for washing purposes in the fifth interspace in 
front, and reopened the posterior opening. There was a discharge 
of 2.835 liters (three quarts) more of thick, fetid pus, making in 
all, at both operations 6.14 liters (thirteen pounds, or six and a 
half quarts). I then introduced into the posterior opening, for want 
of a better tube, a No. 12 catheter, 76 mm. (three inches long), 
the inner end just penetrating the pleural cavity; then, by means 
of a rubber tube and funnel, I passed through the chest 3.78 liters 
(one gallon) of warm carbolated water—temperature 100p, one 
part of acid to eighty. The mass of decomposing fibrin was, of 
course, washed perfectly and disinfected. After the washing the 
temperature fell to 100p, but, as pus accumulated, the temperature 
would rise to 103° or 104°, when, after thorough washing, it 
would again fall to 100°. The washing was repeated from one to 
four times during the day and night. From one to five and a half 
liters (one quart to one and a half gallons) of water was used each 
time as the temperature was high or low, and pus profuse or scanty. 
On the fourth day after the operation, I removed the patient on a 
bed to Chateaugay, where I could oversee the management of him. 
The abscess was discharging about half a liter (one pint) a day at 
this time. The lung had partially expanded, and pressed upon 
the anterior tube the tenth day, so that I was obliged to remove 
it, as it did not rest on the diaphragm. This proved to be a serious 
embarrasment, as by simply injecting into the posterior tube I 
could not reduce the temperature after washing, and the pus 
became more fetid. As the condition of the patient at this poiut 
was very low and critical, I did not dare risk an operation to 
reintroduce the anterior tube, but at each washing a No. 5 
catheter was passed through the posterior tube forward to the 
front of the chest, and a current of water conducted through it to 
the anterior cul-de-sac. This answered the same purpose as the 
anterior tube, and by this means the cavity was thoroughly washed 
from one to four times a day for five weeks. The cavity at this 
time discharged only 60 c.c. (two ounces) a day, but during the 13 
whole time before it discharged daily from 60 to 240 c. c. (two to 
eight ounces). 
The patient now seemed to be improving, and washing was re- 
peated only once a day for a few weeks, when it was stopped en- 
tirely. One serious difficulty in injecting through the posterior tube 
without having any escape from the cavity, was the tearing up of 
the new adhesion between the pleural surfaces, thus exciting 
inflammation. This accident did not occur after injecting through 
the inner tube or small catheter was commenced, as the fluid was 
permitted to freely pass out through the drainage-tube, and no 
pressure was made within the cavity. I noticed that, at the begin- 
ning of the second week from the time of operating, April 5th, 
the lung stopped expanding, and the pleural cavity would be filled 
with air, do the best I could to prevent it. Now, the cavity had 
to be filled, either with pus, water or air, and the air did not seem 
to distress the patient so much as the pus or fluid, when it was 
retained by plugging the drainage-tube; but it prevented the 
expansion of the lung. This led me to have the valved tube which 
I introduced the ninth day after the operation. Through this the 
pus and fluids could drain, and, on expiration, air rushed out of 
the cavity and was prevented from entering on inspiration. The 
lung and chest-walls being thus pulled upon from pneumatic press- 
ure, the lung began rapidly to expand, and at the end of four 
months perfectly filled the cavity with scarcely any perceptible 
deformities of the chest, and, October 1st, six months after operat- 
ing, I removed the drainage-tube and discharged the patient per- 
fectly cured. I think the tube might have been removed at the 
end of the third month. The man is now at work in the silver mines 
of Colorado, and is perfectly rugged. Dr. Wilber, of Constableville, 
Dr. Wentworth, of Malone, and Dr. Chisholm, of Chateaugay, 
saw the patient with me, and examined him when he was under 
treatment. By actual measurement, the amount of water passed 
through the chest during three months was 236 liters (sixty-four 
gallons.) 
The patient was kept upon animal broth, milk, etc. Cod-liver 
oil, iron, wine and quinine Avere given freely. This was, I think, 
a case of pleuritis acutissima of the Germans. 
I am very sure, as the record of temperature will show, that 
unless thorough ablution had been performed, and the pleural 
cavity speedily obliterated by the lung expansion, the patient must 
have died of acute ichorization of the pleural sac. 14 
I used a great amount of ablution because the patient could 
stand it, but I would not recommend this as a routine for all 
cases. But if the discharge is fetid, I would use as much ablu- 
tion and disinfecting as my patient could endure, remembering 
that it is the last straw that may break the camel’s back.