A CONTRIBUTION 
TO THE 
TREATMENT OF EMPYEMA. 
BY 
A. T. CABOT, A. M., M. D., 
SURGEON TO OUT-PATIENTS AT THE MASSACHUSETTS GENERAL HOSPITAL ; SUR- 
GEON TO THE BOSTON CHILDREN’S HOSPITAL. 
[Reprint from the Boston Medical and Surgical Journal of 
A ugust 16, 18831] 
CAMBRIDGE: 
ftriuteir at tt)e Biuersibe Press. 
1883. A CONTRIBUTION 
TO THE 
TREATMENT OF EMPYEMA.1 
Before proceeding to the consideration of the cases 
upon which this paper is based I wish to review briefly 
the mechanical principles involved in the expansion of 
a lung which has been compressed by fluid in the 
chest, and to show how this expansion may be fa- 
vored by an appropriate dressing after the establish- 
ment of a free opening into the pleural cavity. 
Suppose a case of empyema in which an opening has 
been made and the pus allowed to escape. Upon the 
removal of the pressure the lung at once expands some- 
what by virtue of its own resiliency, and by the par- 
tial reestablishment of its circulation. Further, each 
contraction of the chest with closed glottis (cough or 
sneeze) presses the air from the well side over into the 
affected lung, partially expands this, and so forces the 
air or fluid in the pleural cavity out through the open- 
ing in the side. When the cough subsides, and the 
chest again expands, air rushes back to take the place 
of that just expelled. There are two avenues by which 
this returning air enters the chest; namely, the bronchus 
of the lung, and the opening into the pleural cavity. 
If this latter opening be as free and unobstructed as 
the bronchus, the air has as ready access to the pleural 
cavity as to the bronchial tubes, and the pressure on the 
outside and inside of the lung being thus equalized it 
resumes its condition of semi-collapse. 
BY A. T. CABOT, M. T>. 
1 Read before the Section for Clinical Medicine, Suffolk District 
Medical Society. 4 
Treatment of Empyema. 
If, however, the opening in the side is narrowed by 
the closing in of granulations or by the obstruction of 
a dressing, the air returning after a forced expulsion is 
somewhat opposed in its entry into the pleural cavity, 
while the bronchus admits it freely, so that the atmos- 
pheric pressure inside the lung is somewhat greater 
than upon its outer surface, and the dilatation effected 
by the cough is more or less maintained. It is thus 
that nature, with its fistulous openings, provides for the 
expansion of the lung, and we here, too, find the expla- 
nation of the gradual dilatation effected by the usual 
dressings of oakum or other absorbent material. 
This gradual dilatation of the lung is liable to be in- 
terfered with by a provision of nature which here may 
act detrimentally to the healing process. 1 refer to 
the adhesion of the inflamed pleural surfaces when 
brought in contact. Of course, if the surface of a lung 
only partially dilated becomes firmly adherent to the 
parietal pleura, the further dilatation is greatly inter- 
fered with, and may become impossible. It is, there- 
fore, very important to induce the lung to dilate to its 
fullest extent as soon as possible, so that the pleural 
adhesion, when it takes place, may bind things in their 
proper places. That this rapid dilatation may be pow- 
erfully assisted by a proper dressing I shall endeavor 
to show. 
The problem is to provide for the easy escape of air 
and fluids from the chest, and to obstruct the reentry 
of air into it. 
A Lister dressing properly applied fulfills the required 
conditions more thoroughly than any other which I 
have seen in use. The method of application which I 
have found best is as follows : — 
The tubes, of which I generally use two, side by 
side, are arranged so that they barely project within 
the chest wall, and the outer ends, after being securely 
fastened with safety pins and adhesive plaster, are cut 
off as close to the skin as possible. A handful of 
loose gauze wrung out in an antiseptic solution is placed 
around and over them, and over this a piece of mackin- Treatment of Empye7iia. 
5 
tosh large enough to project in every direction beyond 
the gauze beneath it. Over this again are placed many 
(twelve to fifteen) layers of dry gauze, and lastly a 
sheet of cotton batting to provide for equal pressure. 
This whole dressing is held in place by a gauze or 
flannel bandage, some of the turns of which should go 
over the shoulder to prevent its slipping down. 
The loose gauze next the tube catches and holds the 
discharge, which in a favorable case is reduced to al- 
most nothing after the third or fourth dressing, and 
soon becomes serous. 
This rapid diminution of the discharge under anti- 
septic treatment, and the fact that it speedily becomes 
serous in character, was pointed out some years since 
by Professor Lister ; but he did not mention, and I 
have never seen elsewhere described, the great advan- 
tage of this form of dressing in favoring the expan- 
sion of the lung and obliteration of the cavity. This 
latter action of the dressing, which will, I think, be 
sufficiently manifest in the cases I shall report, is due 
to the method in which the mackintosh is applied. 
This rubber layer, impervious to air, overlaps the 
gauze beneath it so that its edges are held closely 
applied to the skin by the elastic pressure outside. 
How closely it clings to the skin can only be appre- 
ciated by one who has frequently removed these dress- 
ings. 
When, now, air is forcibly driven out of the chest by 
a cough, it lifts the edge of the mackintosh somewhat 
and escapes ; but as the elastic outside dressings im- 
mediately press the mackintosh again to the side, the 
air which could lift it from within cannot get beneath 
it from without. It acts, in short, as a valve, allowing 
air to escape from under it, but not to get back again. 
Dr. A. M. Phelps, of Chateaugay, N. Y., in an arti- 
cle in the New York Medical Record for April, 1880, 
upon The Treatment of Empyema by Valvular Drain- 
age, recommends the use of a drainage tube with a 
valve attached which should allow the escajje of fluids 6 
Treatment of Empyema. 
from the chest and prevent the entry of air. This 
contrivance I have never used, as I had already 
found that the antiseptic dressing accomplished this 
same object, with the additional advantage of guard- 
ing against septic absorption. I have, however, seen a 
valvular tube used by Dr. M. H. Richardson, who 
combined it with an antiseptic dressing, but did not 
find that it added to the efficiency of the dressing. 
The cases given in the table on pages 12, 13 will 
illustrate the advantages of the antiseptic dressing, ap- 
plied as 1 have described, both in preventing septic ab- 
sorption and in promoting the expansion of the lung. 
They include all the cases of empyema which I have 
treated in this way, and one case (No. 3) which I saw 
with Dr. J. B. Swift, who operated antiseptically, and 
dressed the patient in the way I have described. All 
of these patients were operated upon under ether ex- 
cept where it is otherwise stated. The final removal 
of the tube in each case is emphasized as giving the 
date when the pleural cavity was finally closed. In 
none of them was there any reaccumulation or further 
discharge, and the opening always closed rapidly. 
Of these fourteen cases, three died and eleven re- 
covered. 
Two of the fatal cases succumbed to phthisis, and in 
the remaining case the effusion had existed so long 
(four years) that the lung was without doubt con- 
verted into a mere fibrous cake at the top and back of 
the chest, and was totally unable to expand. The final 
cause of sudden death is unknown. 
In all of the successful cases the empyema was of 
tolerably recent origin, so that in none of them was 
the lung disabled. The expansion of the lung was 
ordinarily very rapid. In Case 7, for instance, the 
heart had returned to the normal position, and the 
lung had filled the chest at the end of twenty-four 
hours, and this, too, in spite of the fact that the dis- 
ease had existed for three months. This rapid dilata- 
tion can, I think, be fairly ascribed to the suction Treatment of Empyema. 
7 
power of the dressing which I have above discussed. 
The average time that the tube remained in the chest 
was twenty-four days, and this low average cannot be 
accounted for by the influence of the children (who 
notoriously do well) upon the statistics, for the average 
for the four adults is the same (twenty-four days). 
These figures, when compared with the statistics of 
the results of other methods of treatment, will go far 
to illustrate the advantages of the dressing I have de- 
scribed, and I feel sure that to obtain these results the 
mechanical action of the dressing must he intelligently 
regarded. 
Dr. William C. Dabney, in the American Journal of 
Medical Sciences for October, 1882, in an article enti- 
tled “ The Treatment of Empyema,” gives a summary 
of his conclusions as to the value of various methods 
of treatment, and says in a final clause that “ Lister- 
ism would probably be advisable in city or hospital 
practice, but is of doubtful efficacy in the country, and 
under no circumstances should be allowed to interfere 
with through drainage.” 
This conclusion might be true if the only advantage 
of the Lister dressing were in the avoidance of septic in- 
fection. But if we consider the mechanics of the closure 
of these cavities, and seek to assist the expansion of 
the lung, we shall find the close antiseptic dressing a 
powerful aid in bringing about favorable results. 
One of the two tubes introduced at the time of 
operation is best removed when the clots have all es- 
caped and the discharge is reduced to about one fluid 
drachm in the twenty-four hours. The last tube is to 
be finally left out when the discharge dwindles to a 
few drops a day, when in short it is no more than 
would come from the sinus in which the tube lies. 
I think the introduction of long tubes (catheters and 
the like) for injection of the cavity, as recommended 
by Fraentzel, is to be avoided, as you thereby separate 
REMOVAL OF THE TUBE. 8 
Treatment of Empyema. 
the pleural surfaces already adhering and obliterating 
the cavity. 
In the three cases in which the pus was fetid the 
recovery was not in the least interfered with by this 
circumstance. Two of these patients had a chill soon 
after the operation, but no ill effects followed it, the 
temperature rapidly fell to normal and stayed there. 
The odor disappeared in all of them after the third or 
fourth dressing, and recovery was uninterrupted. 
THE FETID CHARACTER OF THE PUS. 
ANTISEPTICS EMPLOYED. 
At first I used carbolic acid exclusively as au auti- 
septic, but soon substituted chlorinated soda for it as 
an injection into the chest, using a solution such as 
described below. This proved so satisfactory that 
I later substituted it entirely for carbolic acid in the 
spray and various solutions, still continuing, however, 
to use carbolized gauze as a matter of convenience, it 
being easily obtained, and never giving rise to carbol- 
ism. 
To show how small an amount of carbolic acid will 
cause poisonous symptoms in these cases I would cite 
Case 12. In operating upon this boy, four years of 
age, chlorinated soda was used for the spray and for 
moistening the inside dressings, but as chlorinated soda 
corrodes the instruments 1 laid them and the rubber 
tube in a carbolic solution, one part to thirty of water. 
This I also used to wash the boy’s side before opera- 
ting, and to cleanse my own hands. The minute quan- 
tity of carbolic acid which was conveyed to the wound 
by the instruments, tubes, and hand of the operator 
sufficed to cause frequent vomiting on the day after 
the operation, and to give the urine a dark, smoky 
color. Treatment of Empyema. 
9 
THE USE OF INJECTIONS INTO THE CHEST. 
Professor Lister advises against the use of injections, 
and regards them as unnecessary. For the simple re- 
moval of the pus injections are certainly not needed, 
but in those cases in which there were purulent clots 
in the chest I found injections of the greatest service 
in removing them, and their complete expulsion is 
very important, as they keep up enough irritation to 
cause a continued secretion of pus, which quickly 
ceases when they are gotten rid of. When the pus is 
fetid, injections not only hasten the disappearance of 
the fetor, but speedily relieve the fever following the 
operation. 
In using chlorinated soda for injections it will be 
noticed that if a strong solution be used it forms coag- 
ula wiili the serum. By the use, however, of a solution 
containing one part of liquor sodas chlorinatse to twelve 
or fifteen parts of water this may be partially avoided, 
and, the coagula are then so soft and gelatinous that 
they readily escape through the tubes, and cause no 
trouble. 
QUESTION OF OPERATION IN PHTHISICAL PATIENTS, OR 
WHEN THE LUNG HAS BEEN LONG COMPRESSED. 
It seems as if little good were to be expected from 
making a free opening into the chest when the exist- 
ence of phthisis is clearly proven, as such a case is 
unavoidably fatal, and the opening, if it is of any avail, 
only unnecessarily prolongs the sufferer’s last days 
with the added distress of a disagreeable discharge 
from the side. Aspiration to relieve urgent dyspnoea 
is the only proper operative procedure in such cases. 
Data are as yet insufficient to decide how long a 
lung may be compressed and yet recover and dilate to 
fill the chest when the pressure is removed. In our 
series two cases in which the compression had existed 
for three months rapidly recovered when the fluid was 
removed. On the other hand, I have seen the lung 10 
Treatment of Empyema. 
reduced to a fibrous cake without a vestige of proper 
lung tissue by two years of compression. Cases of 
course will differ greatly in this regard, and it would 
be well in a doubtful case to aspirate several times, 
and carefully watch the lung, and if noticeable dilata- 
tion follows the aspirations finally to establish a free 
opening. If no dilatation occurs frequent aspiration 
may be sufficient to relieve dyspnoea, and eventually 
to bring about closure of the cavity by collapse of the 
chest wall and approximation of the neighboring or- 
gans. If, however, the pus constantly reaccumulates, 
and gradual exhaustion threatens a fatal issue, a free 
incision and the resection of portions of several ribs are 
clearly indicated to allow the further collapse of the 
chest and closure of the cavity. 
METHOD OF OPERATING. 
In regard to the point selected for the opening, I 
almost invariably opened the chest in the eighth, occa- 
sionally in the seventh, intercostal space, just in front 
of the latissimus dorsi muscle. This place offers sev- 
eral advantages: the chest wall is here thinly covered 
by muscles; the opening is dependent in any ordinary 
position of the body except when lying on the other 
side, and yet is not so far behind as to be directly 
pressed upon when the patient is on the back; it is 
not so low as to be interfered with by the diaphragm 
even when this is considerably pressed upwards, as it 
may be after the fluid is out; it is far enough from the 
shoulder to allow a good dressing to be applied with- 
out interfering with the arm. 
Lastly a word as to the technique of the operation. 
In opening the chest near the base there is always 
danger of injuring the diaphragm, or even, as has 
occurred, the abdominal organs, and the prelimina- 
ry introduction of an aspirator needle is a common 
precaution to gain assurance of the presence of pus 
at the point selected. In some of my first cases I 
used a grooved needle for this exploration, and when Treatment of Empyema. 
11 
pus was found, the groove of the needle guided the 
knife directly into the cavity, and in withdrawing it an 
incision of proper length could be made. The only 
drawback to this method was that with an ordinary 
grooved needle the elastic skin closed into and filled 
the groove, and thus prevented the pus from readily 
showing itself. To avoid this I had the needle, figured 
at the end of this article, made for me by Cod man and 
Shurtleff, instrument makers. It is like an aspi- 
rator needle, with a slit upon one side wide enough 
for the point of the knife to slip along. This form 
makes it impossible for the skin to press into and oc- 
clude the groove, and the pus always escapes readily 
along it. The handle is set at an angle to allow the 
ready use of the knife beside it. After the open- 
ing is made with the knife a director is slipped in, and 
the sharp needle removed. If after the incision one 
CODMAN &, SHURTLEFF, 
BOSTON. 
instrument is withdrawn before another is introduced 
a slight shifting of the muscles may close the opening, 
which is then difficult to find again. The operation 
done thus with an exploring needle is finished ordina- 
rily in a few seconds, and the pain is reduced to a 
minimum, an important consideration when ether can- 
not be administered. 12 
Treatment of Emi^yema. 
6 
£ 
X 
m 
Age. 
Medical Attendants. 
Previous 
Duration 
of Disease. 
Side 
Affected. 
Previous 
Treatment. 
i 
F. 
11 
1 month. 
Right. 
Aspirated 
once. 
2 
M. 
29 
Dr. R. Amory. 
Dr. F. I. Knight. 
Uncertain. 
Right. 
Aspirated 
once. Fetid 
pus. 
3 
M. 
li 
Dr. J. B. Swift. 
2 months. 
Left. Apex 
beat below 
right nipple. 
- - 
4 
m. 
33 
Dr. J. L. Sullivan. 
Dr. F. I. Knight. 
3 months. 
Lett. 
Aspirated 
three times j 
twice serum, 
once pus. 
5 
M. 
14 
Dr. J. L. Sullivan. 
2 months 
Right. 
Aspirated 
five times. 
6 
M. 
22 
Dr. J. W. Elliott. 
Uncertain. 
Left. 
- - 
7 
F. 
11 
Dr. Chandler. 
Dr. F. I. Knight. 
3 months. 
Left. Apex 
beat under 
right nipple. 
Aspirated 
twice. 
8 
M. 
33 
Dr. B. S. Shaw. 
4 years. 
Left. 
Heart beat 
only above 
right nipple. 
Aspirated 
five times; 
four times 
serum, once 
pus. 
9 
M. 
24 
Dr. G. 0. Shattuck. 
Dr. F. C. Shattuck. 
3 weeks. 
Right. 
Aspirated 
once. Fetid 
pus. 
10 
F. 
29 
Dr. II. W. Broughton. 
Dr. H. I. Bowditch. 
Dr. F. II. Williams. 
1 month. 
Right. 
Aspirated 
once. Fetid 
pus. 
11 
M. 
4 
Dr. G. VY. Snow. 
Dr. F. I. Knight. 
1J months. 
Right. 
Aspirated 
three times. 
12 
M. 
3J 
Dr. Hildreth. 
Dr. Dow. 
5 weeks. 
Left. 
Aspirated 
once for di- 
agnosis. 
13 
F. 
26 
Dr. Newell. 
Dr. 11. I. Bowditch. 
6 weeks. 
Right. 
Aspirated 
twice. 
14 
M. 
6J 
Dr. J. A. Dow. 
2 months. 
Right. Treatment of Empyema. 
13 
Date of Op- 
eration. 
Progress. 
Result. 
Remarks. 
March, 
Lung fully dilated 
Tube removed 
The lung was fully 
1879. 
three days after op- 
eration . 
on seventeenth 
day. 
Tube removed 
restored, and child re- 
covered perfect health. 
January, 
Chill after opera- 
Quickly recovered 
18S0. 
tion. Normal tern- 
on twenty-eighth 
full health. 
perature after second 
day. Attended busi- 
ness after ninth day. 
day. 
February, 
Lung dilated rap- 
Tube removed 
Operation without 
1880. 
idly. 
on thir t e e n t h 
ether. Perfect recov- 
day. 
ery. 
May, 
Improved for a 
Died in the au- 
The lung never di- 
1880. 
time, then developed 
phthisis. 
tumn. 
lated satisfactorily. 
June, 
Lung dilated rap- 
Tube removed 
Operation without 
1881. 
idly. 
on twenty-third 
ether. Only one tube 
day. 
introduced. 
J une, 
Lung did not dilate 
Died at end of 
Operation without 
1881. 
well. 
eight months. 
ether, at time regarded 
as palliative, as phthisis 
evidently existed. 
July, 
Heart in normal 
Tube removed 
Complete recovery. 
1881. 
place, and respiration 
on thirty-eighth 
to the base of the 
chest twenty-four 
hours after opera- 
tion. 
day. 
August, 
Lung never showed 
Died suddenly 
In this case two gal- 
1881. 
a sign of dilating. 
on fifty-first day. 
ions of pus by measure- 
ment obtained at the 
operation. Autopsy re- 
fused. 
December, 
Chill after opera- 
Tube removed 
This patient had 
1881. 
tion. Normal tem- 
perature after fourth 
day. Lung dilated 
rapidly. 
on twelfth day. 
pneumonia in the new- 
ly expanded lung soon 
after the pleural cavity 
closed, but with no re- 
accumulation of pus. 
Made a good recovery. 
Seen 1 year later, lung 
in perfect condition. 
March 
Lung dilated well. 
Tube removed 
Opening quickly 
1882. 
on thirtieth day. 
closed. No further 
trouble in the pleura. 
April, 
Tube removed 
Opening quickly 
1882. 
on forty-ninth 
day. 
Tube removed 
closed. 
June, 
1882. 
Rapid dilatation of 
Perfect recovery. 
the lung. 
on thir t e e n t h 
day. 
April, 
Lung dilated rap- 
Tube removed 
Opening quickly 
1883. 
idly. 
on twenty - sixth 
day. 
Tube removed 
closed. 
June, 
Lung dilated rap- 
Opening quickly 
1883. 
idly. 
on tenth day. 
closed. Lung fully re- 
stored.