Chest Drainage in Empyema. 
BY- 
J. J. BROWNSON, M.D., 
-OF 
DUBUQUE, IOWA. 
READ BY TITLE BEFORE THE TRI-STATE MEDICAL SOCIETY, AT 
CHICAGO, APRIL 8, 1896. 
Reprint from the Tri-State Medical Journal, May, 1896. 
ST. LOUIS: 
CONTINENTAL PRINTING CO. 
1896. Chest Drainage in Empyema: 
BY 
J. J. BROWNSON, M.D., 
OF 
DUBUQUE, IOWA. 
Air. President and Gentlemen of the Tri-State Medical Society:— 
WHEN I was invited by the officers of your Association to read a paper 
at its meeting in Chicago, I felt at a loss to know just what subject 
to select; but remembering an incident that happened when I quite a 
young practitioner, it led me to present the subject which I have the honor 
to talk to you about to-day. 
It was many years ago when one day my dear friend and preceptor, the late 
Dr. G. M. Staples, asked me to go and give chloroform for him in a certain 
case. The doctor told me that the patient had had some chest trouble, and 
that he wished to make a thorough examination. When we arrived at the 
house we found a man about thirty years of age, large and stout looking, 
had cough, breathing slightly accelerated. During the afternoons he com- 
plained of feeling chilly, followed by slight fever and sweating. I noticed 
a peculiar color of the skin, not unlike what we would call a “bilious 
look.” 
By request of the physician I made an examination of his chest, but 
there was nothing that I could find out of the ordinary. Imagine my sur- 
prise when the doctor said: “Give him a little chloroform, I think I will 
put in a tube,” and in a few minutes later to see the pus rolling out of 
the thoracic cavity. He then showed me the extent of the dullness and 
oedema, and also pointed to the right side of the sternum where the heart 
♦Read by title before the Tri-State Medical Society, at Chicago, April 8, 1896. beat was located, owing to its displacement by the left-sided effusion. Of 
course, I then became an enthusiast on empyema, and have been so ever 
since. 
It chanced that I had on hand at this time a little boy who had been 
sick for about four weeks, and although he complained of nothing but 
fever and “pain in his stomach,” medicine seemed to have no effect on 
him. After seeing the previously mentioned case, it dawned upon me that 
he might have an effusion in the chest, so I hastened to the house 
to make an examination, and there, sure enough, was the dullness, oedema 
and slight bulging on the left side. Summoning one of my young medical 
friends, who, on his arrival, administered an anaesthetic, I introduced 
the needle of the aspirator, and sure enough pus was found; the needle was 
withdrawn and a tube put in the chest, and about a pint of pus drained 
away. This was my first operation for empyema, and in due form our lit- 
tle patient made a good recovery. 
Since that time, in a moderate surgical and consultation practice, I 
have seen quite a number of cases of effusion in the chest, and to some of 
the points picked up in the recognition and treatment of this condition, I 
will, with your permission, direct your attention. 
It would be needless to take up your time in dwelling upon the history 
of empyema, which dates from the time of Hippocrates, or to discuss its 
various causes so familiar to you all; but rather to proceed at once to con- 
sider the methods of determining in chest disease whether the cavity of the 
thorax contains fluid. Is this fluid pus? If so, what is the easiest and best 
means for its successful treatment? 
The*history of the case may serve to start us on the right 
track, as we would expect to find such a condition following an acute affec- 
tion of the chest; but even here there are so many diseases whose course 
and clinical pictures are so similar that, in many cases, even the most expert 
are sometimes baffled. 
The various phases in pneumonia, pleurisy, pneumothorax, pericarditis, 
exhibit such like conditions, and where pus exists with pneumothorax as in 
pyopneumothorax, I know of no condition where the perplexities are so 
great and where so much care and study is required to make a diagnosis. 
As to symptoms, the most trustworthy in my experience is where hec- 
tic phenomena follow an acute affection of the chest, a continuous acceler- 
ated pulse, breathing rapid and restricted; temperature ranges from 100° to 
102°. The patient, as it were, does not seem to get well, and medicines do 
not make any impression or give relief. If seen in consultation, the doctor 
will almost always say: “The patient’s system does not respond to treat- 
ment.” Such a casein the hands of the average practitioner will almost 
always be a surgical one. 3 
After all, our main reliance must be on the physical signs, for by this 
means we must satisfy ourselves that an effusion exists before we can under- 
take mechanical means to relieve it. Here again we will find many puz- 
zling problems to solve. In a case following the history and symptoms 
previously given, we find, on inspection of the chest, a bulging on one side, 
extreme dullness (“wooden chest”); the side does not expand like the sound 
one; there may be bulging between the ribs. This, in my experience, is 
rare. By succussion, if the effusion be fluid, it may be heard in the pleu- 
ral cavity. One of my friends puts much stress on mensuration, but I 
Fig. i. Trocar and Canula. Rubber Tube. 
must confess that I have not used it much. It must not be forgotten that 
one will often drop onto the fact that an effusion exists on the left side by 
finding the heart displaced to the right of the sternum. 
The signs in which I place the most reliance, however, in addition to 
dullness and immobility of the affected side, are oedema and tenderness. 
Given a case with the foregoing history, symptoms and physical signs, we 
proceed to clear up the diagnosis by exploratory aspiration with a sterilized 
needle. The character of the effusion, if any, will then be determined; if 
it is pus, a tube should be put in at once and thorough drainage of the 
pleural cavity maintained. 
Fig. II. Inserting Tube Through Canula. 
What is the easiest, and at the same time, safest method of successful 
chest drainage? I must say that siphon drainage in my hands 
has given none but the best results. It is easy of performance. It 
drains slowly and thoroughly from the bottom of the pleural cavity. The 
simple method by which irrigation of the chest can be done, if necessary, 
the length of the tube precluding any danger of its retracting into the 
chest—all tend to commend this method for general adoption, rather than 
the more difficult and complicated processes often recommended. I prefer to enter the chest at the point of the most dullness, and over 
the site of the oedema and the greatest tenderness on pressure, although, 
of course, the location of the liver on the right side and the heart on the 
left side must be borne in mind. In the two cases of spontaneous rupture 
outside of purulent effusion which I have seen, both were at the sixth inter- 
space just forward of the axillary line. In general terms I should say 
that the above principles should govern, care being taken not to go below 
the eighth rib on the right side, or the ninth on the left side, unless there 
should be some special indication. 
The mode of procedure is as follows: A trocar, with a canula of about 
one-sixth to one-fourth inch diameter; a piece of rubber tubing about two 
feet long of a size that passes through the canula easily, are needed; the 
instruments, tube and field of operation are now sterilized. It is generally 
best to give chloroform in these cases, and when the patient is sufficiently 
anaesthetized a small incision is made in the skin over the intercostal 
space. The trocar and canula is then pushed in. It is best to enter the 
Fig. III. Siphon Tube in Situ. 
Fig. IV. Tube Shortened, Receptacle carried in Vest Pocket. 
point of the instrument a little upward at first, then downward overthe top 
of the lower rib. If this is done, and the flat side of the trocar directed 
upward there will be very little danger of wounding the intercostal artery 
which runs along the lower border of the rib. The trocar is then removed 
and the tubing passed through the canula to the bottom of the pleural cav- 
ity; the flow of pus can now be regulated through the tube at pleasure. It 
is best to put the end of the tube in a bottle of carbolized water and let 
the matter siphon out; of course, if the patient should feel faint or any 
untoward symptoms appear, the flow may be stopped for a while. I have 
never seen any emergency in letting the pus drain at once. Several strips 
of adhesive plaster are now placed around the tube and fastened to the 
chest, a gauze dressing put on, and the patient allowed to rest comfortably 
in bed. 
It will not be necessary to irrigate the cavity unless the tube gets 
clogged or the temperature should rise. If it is found proper to do this, a 5 
small hard rubber syringe is used to exhaust the air from the tube and 
the end is placed in the irrigating fluid. By raising the vessel the antiseptic 
runs in, and all that is necessary to do is to lower it and the fluid runs out. 
By this method we introduce no air, and we can see at a glance whether all 
the irrigating fluid comes away. 
As the case progresses and the patient becomes convalescent he may 
be allowed to get np and go around. The tube may be shortened and 
placed in a small bottle, which he may carry in his pocket. The tube 
must be left in as long as the discharge is purulent, and should be pulled 
out a short distance occasionally, as healing takes place from the bottom. 
In this way the operator, by previous measurement, knows just how much 
tube is in the chest. 
We can always tell whether things are doing well or not by the range 
of temperature, for “as soon as drainage is made, the temperature falls.” If 
anything interferes with thorough drainage, the “temperature will rise.” 
This is the most important of all surgical axioms and is the principle upon 
which rests the foundation of the whole of surgical science. 
To further illustrate the practical working of siphon drainage in 
empyema, allow me to present a few clinical examples: 
Case I. Roy G., aged 6 years; taken with pain in the chest, fever, 
cough. The usual remedies were ordered; he improved somewhat, but at the 
end of two weeks resolution did not take place, but he commenced to have 
hectic symptoms. Physical examination developed dullness and marked 
bulging on the left side; there was oedema, and the point of most tender- 
ness was over the sixth interspace in the axillary line. Aspiration at this 
point showed pus. The skin was incised and siphon drainage used, and 
about a pint of matter drained away. The temperature dropped to normal 
and at the end of two weeks the tube was shortened, and he was allowed to 
attend a picnic some miles distant. About the ninth week the tube was 
removed and he has since been well. 
Case II. C. K., aged 40 years; first sick with chills and pain in the 
left side; had fever and cough, and after several days the breathing became 
very much embarrassed. The heart was found displaced to the right of the 
sternum, and dullness and oedema were present. Aspiration was performed 
on the left side in the seventh interspace, from which pus exuded. Siphon 
drainage was then made, and the matter allowed to drain away. Patient 
made a good recovery, and the tube was removed in two months. 
Case III. W. S., aged 4 years; had measles. In the usual time the 
rash disappeared, but the cough persisted, and the dyspnoea became so 
great that he could not lie down. Physical examination of the chest 
revealed dullness and bulging of the whole right side. Chloroform was 
given; aspiration withdrew pus; siphon drainage was made and the effu- 
sion allowed to drain away. This gave him immediate relief, and in less than a week he was around the house with the tube in a bottle and he 
passed on to a good recovery. 
Case IV. G. H., aged 9 years. Attack commenced with symptoms 
of pleuro-pneumonia, the patient continued to get worse from time to time. 
Nine weeks after she was taken sick dullness developed over the right side 
and she had a dry and incessant cough, which annoyed her every minute. 
Dyspnoea was well marked, and there was considerable oedema and tender- 
ness over the whole area. A diagnosis of empyema was made, which sub- 
sequent aspiration confirmed. Siphon drainage was then done. Every- 
thing went well until the end of the first week, when, while washing out 
the cavity, the child took a fainting and coughing spell, from which she 
was with difficulty revived. The irrigation was then stopped, and with 
this exception she did well. The tube was removed in nineteen weeks. 
Case V. J. S., resident of Earlville, Iowa, 22 years of age, presented 
himself with a history of having had two months previously an attack of la 
grippe. He did not recover from this, but developed hectic symptoms and 
sustained a considerable loss of weight. He had a cough with profuse 
purulent expectoration and a diagnosis of tuberculosis had been made by 
two physicians. On physical examination there was found dullness, oedema 
and marked tenderness on the right side. These appearances, together 
with the peculiar coppery or bilious color of the skin, led to a determination 
of empyema with rupture into the bronchi. Subsequent aspiration con- 
firmed this opinion, and incision in the seventh interspace on the right side 
was made and siphon drainage put in. The young man was very much 
relieved by this procedure and eventually recovered. 
Case VI. P. S., age 9 years. Sickness began with fever, cough and 
rapid breathing. His appetite remained good, but the pulse and breathing 
increased. Physical signs showed resonance on both sides, except that 
there was slight bulging on the right side; there was no evidence indicat- 
ing effusion. Aspiration was, however, performed in the seventh inter- 
space on the right side, but showed nothing but blood. The symptoms 
continued to get worse, when, after he had been sick about nine weeks, a 
small spot of dullness, with oedema and extreme tenderness, developed in 
the interspace just below the left scapula. Aspiration at this point found 
pus, and the drainage tube was now put in. About four ounces of matter 
drained away. The tube was deft in about a week, when there having 
been no discharge since the first day, and the symptoms having abated, it 
was thought best to remove it. The little boy made an uneventful recov- 
ery and is now thoroughly well. 
In the previously cited cases I have endeavored to give only an exam- 
ple of those which present different phases. I now wish to give an illus- 
tration of how nature attempts to cure empyema by spontaneous opening 
externally: 7 
I 
Case VII. L. P., aged 29 years, took sick in the country with chest 
symptoms, lung fever being diagnosed by his physician. He continued 
very ill for about four weeks when pus broke out in two places on the right 
side of the thorax. Following this he made a slow recovery, but the dis- 
charge did not stop, and for this condition he came to the city some six 
months later. There were two sinuses in the sixth interspace on the right 
side, which led into the chest. Drainage was made in the seventh space, 
the tube passing to the bottom of the pleural cavity. The sinuses promptly 
closed and at the end of four weeks the tube was removed and he has since 
been well. 
Case VIII. A. G., aged 60 years. Had pleurisy six months pre- 
viously; has had cough and purulent expectoration. About three months 
ago a small sinus appeared over the sixth rib, and on introduction of a 
probe necrosed bone was felt. A diagnosis of necrosis of the rib was made 
and exsection of same advised. At the operation the necrosed rib was 
removed, and underneath it was a thickened condition of the pleura, with 
a large pocket of pus. This was certainly nothing more than an old em- 
pyema, and in its attempt at evacuation caused necrosis of the rib. 
Thorough drainage of the cavity was made and the man went on to a good 
recovery. 
I might go on and give descriptions of numerous cases, but my 
paper has now already taken up too much space, and I merely wish to say 
in conclusion that I believe many valuable lives are lost by a failure to 
recognize and properly treat this disease. If I have succeeded in calling 
attention to the fact that when a physician has a case of persistent symp- 
toms following an acute affection of the chest, together with the signs of 
dullness, oedema and tenderness, he should not hesitate to use an aspirator 
to clear up the diagnosis, and if you will only overlook any little omissions 
or irregularities in this paper, for I have written it off-hand so as to bring 
you all near the bed side, I shall feel amply repaid and truly thankful for 
the courtesies extended in allowing me to present one of the most interest- 
ing and life-saving operations in the whole domain of surgery.