Reprinted from 
ANNALS OF SURGERY 
April, 1893 
ANNALS 
SURGERY 
t, MONTHLY REVIEW OF SUROICAL SCIENCE ANO PRACTICE 
EDITED BY 
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A STUDY OF SEVENTEEN CASES OF EMPYEMA. 
By JAMES P. WARBASSE, M.D., 
OF BROOKLYN. 
ASSISTANT SURGEON, METHODIST EPISCOPAL HOSPITAL. A STUDY OF SEVENTEEN CASES OF EMPYEMA. 
JAMES P. WARBASSE, M.D., 
OF BROOKLYN. 
ASSISTANT SURGEON, METHODIST EPISCOPAL HOSPITAL. 
INASMUCH as the rational therapy of empyema belongs to 
the realm of surgery, empyema may be regarded as essen- 
tially a surgical disease. It is not the intent of this paper to 
discuss the pathology, the symptomatology or the treatment of 
the disease, but to present a series of cases, and deduce from 
them whatever lessons they may teach. 
These cases occurred in the services of Drs. Pilcher and 
Fowler, in the Methodist Episcopal Hospital, in Brooklyn. The 
very brief histories herewith given are abstracted from the more 
elaborate histories in the archives of the hospital. The common 
symptoms of empyema presented by the cases, either before or 
after the operation, are not given unless they have some special 
feature. In all cases, the operations were conducted as asepti- 
cally as though a fresh wound were to be made in normal tissue. 
The operators were not influenced by the mistaken idea that " pus 
is pus," but took the precautions which modern surgery has at 
command to prevent the nocuous infection of innocuous pus. 
In the cases subjected to operation, it was the custom to strip of 
its periosteum and vessels the portion of rib to be resected and 
remove only the bone. In order to prevent the danger of col- 
lapse in feeble patients, the rapidity of the escape of pus was les- 
sened by introducing the finger into the wound, or by placing 
some obstruction at the surface. Drainage tubes were introduced 
in all cases. Usually two fenestrated rubber tubes were used. 
Irrigation of the cavity with warm aseptic or antiseptic solution 
was practiced. For this purpose boro-salicylic, hydro-naphthol, 
normal salt solution or distilled water was employed. None but 
sterilized dressings were used. After the operation, as the lung 
expanded, and the amount of discharge became less, the tubes 2 
JAMES P. WARBASSE. 
were shortened from time to time, and were usually discarded 
about the fourth week. The frequency of dressing was governed 
by the amount of discharge. During the first week it was usu- 
ally necessary to change the dressings every day. Irrigation was 
practiced at the dressings when the discharge was septic in char- 
acter. The cases were placed on tonic treatment, and the pain 
and cough of irritation were combatted with appropriate remedies. 
These features, common to all of the cases, are omitted from the 
brief histories below, unless they present some peculiarity. 
Case I.-Female, forty-two years. Six weeks prior to admission 
to the hospital the patient developed an idiopathic pleurisy of the left 
chest. The active symptoms subsided, but she continued to lose flesh 
and strength, and was admitted in a much reduced condition. Phys- 
ical examination showed fluid filling the lower half of the left pleural 
sac. Pus was obtained by introducing a needle in the eighth space 
in the mammary line. On the third day after admission she began 
to expectorate large quantities of purulent matter, and presented the 
physical signs of rupture of pleural pus into the lung. 
Operation.-Three inch incision over sixth rib. One and one- 
half inches of rib excised in axillary line. Pleura opened and a large 
amount of greenish pus evacuated. At the same time a considerable 
quantity of purulent fluid escaped from the mouth. 
During the four weeks subsequent to the operation the discharge 
from the wound, which for the first few days was profuse, gradually 
became less. The wound was irrigated daily through the tube. The 
lung expanded well. The expectoration, which immediately after the 
operation was composed of bloody pus, entirely subsided. Aside from 
a slight, irritable cough, and occasional pain at the site of the wound, 
the patient was well when she was dismissed, two months after 
admission. 
Before the operation the temperature fluctuated between 990 and 
102.50. The pulse rate had gradually increased up to 135. Respi- 
ration was 30-35. After the operation the temperature fell to normal. 
For twenty-four days the evening temperature continued to rise 
slightly above normal. It then subsided. The pulse rate gradually 
sank to normal. Respiration remained at 38 for three days subsequent 
to the operation, and then steadily decreased. 
Case II.-Male, eleven years. A delicate child. Acute symp- 
toms three years before admission. Symptoms of pleuritis with SEVENTEEN CASES OF EMPYEMA. 
3 
effusion were followed by symptoms of empyema of the right chest, 
with perforation into the lung. For two years the patient had been 
coughing up large quantities of pus. His general condition became 
much worse. A fluctuating tumor finally appeared directly under the 
right nipple, which increased in size until it reached three inches in 
diameter. 
Operation.-The tumor was incised and pus and necrotic debris 
were evacuated. No opening into the pleural cavity was discovered. 
A section of bone was removed from the subjacent rib. 
The pleura was found greatly thickened. There was so little 
evidence of fluid within the pleural cavity that the pleura was not 
opened. 
After the operation, during the attacks of coughing, air passed 
in and out through the wound. A considerable discharge of pus 
persisted. 
Aspirating needle introduced in sixth space discovered no pus. 
Pus obtained in seventh space in the axillary line. Section of seventh 
rib excised. Pleura opened and considerable pus liberated. The 
pleura was very dense and thick. For ten days following the opera- 
tion there was a copious discharge. The patient's general condition 
improved very much after the second operation. Both wounds healed 
firmly. 
After the first operation the temperature, pulse and respiration 
rates continued above normal; after the second operation they 
gradually subsided. 
At the present time, three and one-half years after the operation, 
the patient enjoys good health, and has no symptoms referable to the 
chest. He has a right concave scoliosis of so marked a degree as to 
produce a very noticeable deformity. The right chest in its lower 
part is bound down and contracted, and the left chest has undergone 
compensatory enlargement. The scoliosis is most marked in the 
upper dorsal segment. 
Case HI.-Male, eight years. Empyema of left chest subse- 
quent to pneumonia two years before admission to hospital. Tumor 
appeared below nipple, was incised and pus evacuated. At the time 
of admission, eighteen months later, this was still a discharging sinus. 
Patient was much emaciated. 
Operation-Incision in axillary line exposing fourth, fifth, sixth 
and seventh ribs. One and one-half inches of each rib resected. 
Pleura opened at site of sixth rib. A large amount of foul-smelling 
pus evacuated, 4 
JAMES P. WARBASSE. 
An abundant discharge of pus continued after the operation, 
necessitating frequent dressings After the fourth day irrigation of 
the cavity with tincture iodi i : 250 was begun. The amount of dis- 
charge steadily decreased, the lung expanded, and the cavity con- 
tracted and closed. The patient's general condition was much 
improved. He became robust and felt perfectly well. 
After operation the temperature sank to subnormal, and then 
gradually ascended. 
Case IV.- Male, twenty-one years. An advanced case of 
phthisis admitted to the surgical service from the medical service with 
the diagnosis of pyopneumothorax following the rupture of a tuber- 
culous cavity through the pleura. The pus dullness had steadily 
increased till it occupied the lower half of the left pleural cavity. 
The lung lesion was very pronounced and the patient was in extremis. 
Respiration 30 to 40 ; chloroform was administered, and at the time 
when surgical anaesthesia was reached respiration ceased, and heart 
failure followed in a few seconds. Faradism and artificial respiration 
were of no avail. The autopsy showed a large amount of pus in the 
pleural cavity and extensive tuberculous destruction of the lungs. 
Case V. - Female, forty-four years. In childhood patient 
suffered with tubercular coxitis and spondylitis, resulting in a marked 
kyphosis. Nine months before admission she developed pleurisy on 
the right side, with effusion, following pneumonia. This soon became 
an empyema, and patient became greatly prostrated. Aspiration 
showed pus. 
Operation.-Incision in axillary line parallel over eighth rib. 
Two inches of rib removed. Exploring needle found pus, and the 
incision was continued through the pleura. About one pint of thin 
pus escaped. Irrigated with normal salt solution. 
The discharge, which at first was profuse and offensive, gradually 
became less, and the patient's general condition steadily improved. 
Three weeks after the operation the discharge had practically ceased, 
and the patient was dismissed. 
Before the operation the temperature ran along at 990. After 
the operation it steadily rose, reaching its maximum, 101°, on the 
third day. From this it subsided to normal. 
At the present time, thirteen months after operation, the patient 
is well and strong, and has no chest symptoms, excepting an occa- 
sional pain on the affected side. 
Case VI.-Male, sixty-three years. Patient was operated upon SEVENTEEN CASES OF EMPYEMA. 
5 
for papilloma of the bladder, and while still in the hospital developed 
double idiopathic pleurisy with effusion. Resolution took place on 
the right side, but the left became an empyema. Sixty-eight ounces 
of thin pus were drawn off with the aspirator. Five days later a 
resection of two inches of the eighth and ninth ribs was done, and a 
considerable amount of pus liberated. Seven weeks after the opera- 
tion the wound was perfectly dry. The temperature sank after the 
aspiration and after the rib resection. On account of wounds else- 
where, its curves can not be attributed alone to the empyema. 
The above cases occurred in the service of Dr. Fowler ; the 
following are from the service of Dr. Pilcher. 
Case VII.-Male, thirty-two years. This case was brought to 
the hospital in extremis. Physical examination showed fluid in the 
left pleural cavity, and advanced tubercular disease in both lungs. 
His condition was so low that operation was not deemed advisable. 
The left pleural cavity was aspirated, and four ounces of pus drawn 
off. The patient continued to sink, and in the course of twenty-four 
hours died. 
Case VIII.-Female, fen years. Patient was admitted with 
double empyema of idiopathic origin. Pulse rapid and feeble; 
breathing rapid and insufficient; face cyanotic. 
Operation.-Two inches of eighth right rib removed at the 
angle. Pleura opened, and a large amount of pus containing cheesy, 
inspissated matter was liberated. 
The operation was followed by marked prostration. 
Seven days later, when the patient had rallied, a second opera- 
tion was done on the left side. Two inches of eighth rib were 
excised at the angle. Eight ounces of pus and cheesy material were 
liberated from the pleural cavity. Irrigated with distilled water. 
After each of the operations the patients suffered much pain and 
exacerbations of coughing. Her general condition was better after 
the second than after the first operation. The pleurae were irrigated 
daily. Tubes were removed on the seventeenth day after the respective 
operations. Convalescence was rapid. Eight weeks after admission 
both wounds were solidly healed. 
After the operations, the temperature and pulse rate were lowered, 
but continued up to the time of her discharge slightly above normal. 
The respiration rate, which after the first operation was 70-80, 
gradually decreased to 30. 6 
JAMES P. WARBASSE. 
At the present time, eighteen months after her discharge from 
the hospital, the patient is a robust, healthy child. At the seat of 
the right cicatrix is a depression slightly more than i cm. deep. The 
respiratory murmur over the scar is normal. Below the seat of 
operation the pulmonary resonance is dull, and the breathing sounds 
are very faint. On the left side the resonance below the scar is 
slightly dull; respiratory murmur normal. There are no symptoms 
referable to the chest, excepting an occasional slight irritable cough. 
She takes a full breath without producing pain or rales. A slight 
tendency to habitual dorso-lumbar kyphosis has developed since the 
operation. 
Case IX.-Female, five years. After a pneumonia, three months 
before admission to the hospital, a pleural effusion developed in the 
left chest, which was continuous with the subsequent objective and 
subjective symptoms of empyema. On admission there was a very 
perceptible bulging of the intercostal spaces on the left side. Pus 
was discovered with the aspirating needle in the eighth interspace. 
Operation.-One and one-half inches of ninth rib removed just 
posterior to posterior axillary line. Thick, yellow pus liberated from 
pleural cavity. Three large drainage tubes introduced. The lung 
gradually expanded, and the case went on to complete closure of the 
sinus. 
After the operation the temperature and pulse rate diminished. 
The respiration rate increased slightly-from 35 to 37-40. 
At the present time, seventeen months after the operation, the 
patient has no symptoms referable to the thorax, excepting an occa- 
sional neuralgic-like pain following exposure to cold. There has 
developed since the operation a slight right convex dorsal scoliosis. 
The respiratory murmur and pulmonary resonance over the seat or 
operation are normal. 
Case X.-Male, forty-four years. This patient had previously 
been a healthy man. Three months prior to admission to hospital, 
among other symptoms, he developed violent epigastric pain and 
vomiting. He was unable to swallow solid food. Four weeks later 
pain developed in the lower part of the right chest, which he inter- 
preted as pleurisy ; and in the course of three weeks more he began to 
experience more pain about the free border of the ribs. He became 
much prostrated. 
At the time of his admission to the hospital he presented the 
symptoms of an empyema of the right chest, extending up to the SEVENTEEN CASES OF EMPYEMA. 
7 
fourth rib. The aspirating needle introduced in the seventh space 
discovered pus. 
Operation.-One and one-half inches of the rib, just anterior to 
angle, removed. Two quarts of greenish, foul-smelling pus, contain- 
ing necrotic debris and jelly-like material, evacuated. While the 
fluid was escaping from the wound the patient collapsed, and required 
vigorous stimulation. The diaphragm was found perforated, and a 
large abscess cavity in the liver. Active stimulation was continued, 
but patient steadily sank and died in fourteen hours. 
Case XI.-Female, twenty-four years. History of pneumonia 
ten years before admission to hospital. Five weeks prior to admission 
the symptoms which terminated in empyema began. At the end of 
four weeks an opening spontaneously occurred in the left chest wall 
in the sixth interspace in the nipple line, and discharged some pus. 
On admission a considerable current of air passed in and out through 
this opening with the respiratory movements. The patient was feeble 
and emaciated, Delirious at times. Feet and legs cedematous. 
Bed sore on left hip. Physical examination discovered signs of 
bronchial fistula. 
Operation.-Cocaine Til 30, 4 per cent, solution. One inch of 
ninth rib resected. Pleura opened and pus liberated. Not irrigated. 
On the following day the patient's condition was very low. The 
discharge from the wound was profuse. On the third day after 
the operation she died. Autopsy showed miliary tuberculosis. 
Nearly the whole of left lung was involved, and the right was com- 
pletely consolidated. 
Case XII.-Female, thirteen years. Two years prior to 
admission to hospital an abscess of empyemic origin spontaneously 
ruptured in the right lumbar region. The sinus continued to dis- 
charge. 
Operation.-One inch of tenth rib excised just anterior to angle. 
Pus discovered in pleural cavity. Old sinus curetted. Tubes intro- 
duced through both openings. Subsequent treatment with hydrogen 
peroxide and iodoform emulsion resulted in a complete cessation of 
the discharge and a closing of the sinuses. At the end of six weeks 
the patient was discharged cured. 
At the time of operation the temperature was normal. After 
the operation it arose to ioo° F. and then gradually subsided. 
Until a week ago, which was seven months after the operation, 
the patient had been well and strong. She had steadily improved 8 
JAMES P. WARBASSE. 
since leaving the hospital, and the wounds remained solidly closed. 
One week ago the original sinus spontaneously reopened and a small 
amount of pus escaped. 
Case XIII.-Female, twenty-five years. Six months prior to 
admission to hospital patient developed a septic condition following 
child-birth. This was in turn followed by purulent pleuritis. Three 
months later a tumor appeared in the right sixth intercostal space, a 
little external to the nipple line. This was incised, and a sinus 
persisted. 
Operation.-Sinus curetted. Section of ninth rib removed i.n 
axillary line. Large quantity of foul, thick pus escaped. Irrigated, 
and scraped with a blunt spoon. 
Two weeks after operation patient was absent from hospital for 
several days. Soon after this the wound closed and the febrile 
evidences of retention appeared. The wound was reopened and a 
considerable amount of retained pus was liberated. Under treatment 
with hydrogen peroxide and io per cent, iodoform emulsion, the 
secretion diminished. At the end of three months the patient was 
dismissed from the hospital with her general condition very greatly 
improved, but with a small and gradually closing abscess cavity. 
Before operation the temperature ranged from normal, to ioi° ; 
pulse, 120-160; respiration, 25-30. At the time of her discharge 
from the hospital the temperature and pulse rate were normal and 
respiration was 20-25. 
Since her discharge the sinus has closed on three occasions, and 
been reopened. A bronchial fistula was present, as evidenced by the 
fact that medication introduced into the wound was coughed up 
and spat out. At the present time the wound has been solidly closed 
for five weeks. 
Case XIV.-Female, thirty years. A bullet from a pistol entered 
the patient's back, piercing the left sixth rib two and one-half inches 
from the spine, and lodged under the skin at the upper side of the left 
breast. Four weeks after the injury the expectoration, which had 
previously been bloody, began to show traces of pus, and the patient 
presented the symptoms of empyema. One week later one and one- 
half inches of the ninth rib in the posterior axillary line were excised. 
A large amount of foul-smelling, bloody pus was evacuated from the 
pleural cavity. The finger introduced discovered free spicules of 
bone lying in the bottom of the pleural sac. The foreign matter was 
removed and two large drainage tubes inserted. The after-treatment SEVENTEEN CASES OF EMPYEMA. 
9 
of the wound was the same as in the other cases of empyema. Later 
on, hydrogen peroxide and iodoform emulsion were employed, and 
ultimate sound healing of the wounds was secured. 
Before the operation the temperature was irregular, ranging from 
normal to 103.6°. At the time of operation it had been steadily 
going down, and had reached normal. After the operation it grad- 
ually arose, reaching its maximum, 104.20, on the tenth day. From 
this it steadily declined to normal. 
Case XV.-Male, nine years. Acute idiopathic pleuritis, four 
weeks before admission, resulted in empyema of the right chest. The 
patient became greatly emaciated and prostrated. 
Operation.-One and one-half inches of ninth rib removed in 
the posterior axillary line. A large amount of pus and thick, floccu- 
lent material evacuated. The lung was found retracted beyond the 
reach of the index finger. The tube was removed on the tenth day. 
The lung expanded well. The general condition of the patient 
rapidly improved, and at the end of five weeks the wound was per- 
fectly healed and dry. 
After the operation the temperature, respiration and pulse rates 
steadily diminished. 
Case XVI.-Male, thirty-seven years. Admitted greatly pros- 
trated with advanced chronic phthisis, and empyema due to rupture 
of a tuberculous cavity into the left pleural sac. The resection of a 
portion of rib was done in the axillary line. Pus and necrotic debris 
were evacuated. The patient continued to sink, and survived the 
operation but four days. 
Case XVII.-Male, twenty years. Acute symptoms began three 
weeks previous to admission to hospital, when patient developed a 
pneumonic process in the left lung, with gangrene of pulmonary 
tissue. He coughed up foetid matter and presented the physical signs 
of cavity in the lung. Admitted to hospital with pyopneumothorax. 
One inch of ninth rib resected and a large amount of stinking pus 
liberated. At the end of a week he was greatly improved. On the 
tenth day the symptoms of pneumonia in the previously sound lung 
developed, which terminated fatally at the end of six days. Autopsy 
showed large cavity in left lung and pneumonic consolidation in 
lower lobe of right. 
After the operation the temperature declined gradually from 103° 
to normal, and then as the complication in the other lung developed, 
it rapidly rose until the end. JAMES P. WARBASSE. 
10 
Of these seventeen cases six were of idiopathic origin; four 
followed pneumonia; four were preceded by pulmonary tubercu- 
losis ; one was associated with puerperal septicaemia; one followed 
the rupture of an abscess of the liver through the diaphragm ; 
and one was traumatic in origin. In one of the idiopathic cases 
both sides were involved. 
The four cases, IV, VII, XI and XVI, which were compli- 
cated with tuberculosis, all terminated fatally. Case IV, in which 
a tuberculous cavity in the lung had ruptured through the pleura, 
and given rise to pyopneumothorax, died during the anaestheti- 
zation. Case XVI, of the same character, survived the operation 
four days. Case XI, in which had spontaneously developed a 
sinus through the chest wall, and a bronchial fistula, died on the 
third day after the operation. And Case VII expired within 
twenty-four hours after admission, four ounces of pus having 
been aspirated from the chest. These four cases presented ad- 
vanced tubercular disease of both lungs. Of the two remaining 
fatal cases, X and XVII, the first, which had for its aetiology the 
rupture of a liver abscess into the pleural sac, died a few hours 
after the operation for empyema; and the second perished from 
a complicating pneumonia in the previously sound lung. 
rhe ages of the cases of idiopathic origin were respectively 
nine, ten, eleven, thirteen, forty-two and sixty-three. Those fol- 
lowing pneumonia were five, eight, twenty and forty-four. The 
cases associated with pulmonary tuberculosis were twenty-one, 
twenty-four, thirty-two and thirty-seven. 
Of the cases of single empyema not traumatic in origin 
six involved the left side, and nine involved the right side. 
Spontaneous evaluation occurred in four cases into the lung ; 
in one case through the chest wall; and in one in the lumbar 
region. Three more cases presented a single, thin-walled, fluc- 
tuating tumor of the chest, which, in the course of time, would 
have spontaneously ruptured. 
. In Cases I, II, VI, VIII, IX, XIII and XV the temperature 
gradually subsided after the operation. In Case V, in which the 
pus was foul smelling, the temperature, which at the time of 
operation was 990, gradually rose for three days after the oper- SEVENTEEN CASES OF EMPYEMA. 
11 
ation, and then subsided. Case XIV, from which foul-smelling 
pus was evacuated, had a normal temperature at the time of 
operation, which, after the evacuation of the pus, steadily rose to 
104.2°, and then subsided to normal. The temperature in Case 
XII, which previous to the operation was normal, gradually rose 
after the operation and then subsided. 
In the majority of cases the respiration rate decreased after 
the operation. In Cases I and IX it increased for several days 
after the evacuation of the pus, and then diminished. 
Of the fifteen cases subjected to operation it is now known 
that nine are cured ; one, which cannot be communicated with, is 
probably cured ; and one, though greatly improved, has recently 
had a recurrence of the discharge from the old sinus. Six cases 
died : four with operation, and two without operation. 
Habitual spinal curvatures, of a greater or lesser degree, have 
been observed in the cases of the younger patients. 
What may we conclude from a study of these foregoing 
cases ? It is to be regretted that the fluids were not subjected to 
bacteriological examination. Inasmuch as this is the case, an 
opinion as to their aetiology has little scientific value. This is 
especially true of the so-called idiopathic cases. In all proba- 
bility the tubercular cases, IV, XI and XVI, in one of which was 
a sinus through the chest wall, and a bronchial fistula, and in 
the other two, perforated tuberculous cavities, contained, besides 
the tubercle bacillus, the pyogenic staphylococci and streptococci. 
These two last cases cannot be regarded as tubercular pleurisy at 
all, but as a violent septic pleuritis, due to infection from an abscess 
cavity, with its numerous varieties of pyogenic micro-organisms. 
The four tubercular cases tend to corroborate the lesson 
which many surgeons urge, that pulmonary tuberculosis, com- 
plicating an empyema, constitutes a contra-indication to operative 
interference. In all of these cases, the empyema developed only 
when the tuberculous destruction of pulmonary tissue had reached 
a very advanced stage. The patients were already affected by a 
disease which, had the empyema not occurred, would, in itself, 
almost certainly have led to a fatal issue. 
Whether the cases following pneumonia had for their aetio- 
logical factor the pneumococcus must always remain a question. 12 
JAMES P. WARBASSE. 
The aetiology of Case X has some obscure points ; and the 
question may be ventured as to which was the primary lesion- 
the empyema or the abscess of the liver ? The pain, which the 
patient referred to the free border of the ribs over the liver, was 
possibly due to an adhesive peritonitis between the upper surface 
of the liver and the diaphragm, followed by the perforation. The 
fact that this pain was preceded by the subjective symptoms of 
pleurisy might point to a lesion primarily of the pleura. On the 
other hand the pronounced gastric symptoms which marked the 
onset of the trouble, with the pain about the liver, and the oesopha- 
geal stenosis, speak more for the primary lesion of that organ ; 
and it is most probable that the pain, which was subjectively 
interpreted as pleuritis, was a diaphragmatic peritonitis, which pre- 
ceded the perforation of a liver abscess into the pleural cavity. 
Although spontaneous evacuation occurred in six of the 
seventeen cases, leaving out of account those caused by perfora- 
tion of tuberculous cavities into the pleura, the opening was 
external in only two ; and neither of these was in the most favor- 
able location. From the experience with these cases, it may be 
deduced that it is unwise and dangerous to allow an empyema to 
pursue its natural course with the hope of a spontaneous cure 
being effected, when an operation, which, in itself, is attended with 
far less danger than the natural course of the disease, can be 
performed. 
Why certain cases, from some of which foul-smelling and 
evidently septic pus was evacuated, developed higher temperatures 
after the evacuation of the pus than they had presented before the 
operation, can be accounted for in one or more of the following 
ways : The low temperature before the operation may have been 
because, (i) the pus was contained in a cavity inclosed by a 
thickened wall, covered with fibrinous deposit, rendering its sur- 
face incapable of readily absorbing septic material; (2) the tension 
upon the walls of the pus cavity so impeded the blood and lymph- 
atic circulation that absorption was, to a greater or lesser degree, 
hindered ; (3) the patient may have gradually become immune to 
the action of the ptomaines, which for a long time were constantly 
being absorbed in small quantities ; (4) the pus may not have SEVENTEEN CASES OF EMPYEMA. 
13 
been a septic pus. The subsequent rise of temperature may have 
been due to the fact that (i) the operation wound and the break- 
ing up of adhesions within the pleural cavity opened chinks and 
channels for the admission into the connective tissue spaces of the 
thorax of septic material which had been previously enclosed by 
non-absorbing surfaces; (2) infection from without may have 
occurred at the time of operation ; (3) the febrile movement may 
have been simply the fever of irritation so often observed after 
operation or injury; (4) it may have been due to constitutional 
causes other than the empyema. 
The fact that the younger patients show so marked a ten- 
dency after operation to habitual spinal curvatures, demands more 
than a passing notice. There is in these cases the inevitable ten- 
dency to flex the dorsal vertebrae toward the diseased side. It 
arises from the greater comfort which is gained by the position, 
and the natural tendency of the chest, emptied of a part of its 
contents, to collapse. The patient finds that this position immo- 
bolizes, to a certain degree, the tissues about the wound, and 
diminishes the painful friction of the opposed pleural surfaces. 
This, in connection with the collapse of the diseased chest, and 
the compensatory emphysema of the sound lung, tends to throw 
the spinal column in lateral flexion toward the affected side. 
Anatomically the deformity is not so much due to muscular 
atrophy as to the intra-thoracic adhesions and the ligamentous 
and fibrous changes in the walls of the thorax, which occur in 
parts fixed for a considerable period of time in one position. The 
muscular degeneration is secondary to these changes. It there- 
fore commends itself, that an effort be made soon after the opera- 
tion to prevent this sequel. Let the spinal column be immobil- 
ized by some mechanical means, as a light plaster-of-Paris jacket; 
and, either immediately or as the diseased lung expands, let the 
tendency to deformity be gradually corrected, until finally the 
convexity of an artificial scoliosis is made to look toward the dis- 
eased side. The spine may be retained in this over-corrected posi- 
tion until the lung has fully expanded, and the danger of an 
habitual spinal curvature is passed. When the wound has 
become permanently healed, such gymnastic exercises and mas- 
sage as shall develop the diseased chest should be inaugurated.