REMARKS UPON EMPYEMA. 
BY 
MARY PUTNAM JACOBI, M.D., 
OF NEW YORK. 
FROM 
THE MEDICAL NEWS, 
February i, 8 and 15, 1890. [Reprinted from The Medical News, Feb. 1, 8 and 15, 1890.] 
REMARKS UPON EMPYEMAd 
By MARY PUTNAM JACOBI, M.D., 
OF NEW YORK. 
I do not propose to enter into an exhaustive statis- 
tical discussion in regard to empyema or its treatment. 
This ground was largely, though not completely, cov- 
ered in a discussion held at the New York Academy 
of Medicine, in the winter of 1887, in which several 
physicians and surgeons took part. I may add that 
this discussion yielded more positive and useful con- 
clusions in regard to the treatment of empyema than 
were reached by the discussion of the International 
Congress at London, in 1881. In six years, a most 
substantial progress had been effected. 
The physiological problems involved in empyema 
have been discussed theoretically and experimentally, 
as recently as last September, at the first meeting of 
the American Pgediatric Society, held in Washington. 
This discussion was sustained by Drs. O’Dwyer and 
Northrup, and the President of the Society, all from 
this city. 
It might easily seem, therefore, that nothing re- 
1 Read before the New York Academy of Medicine, Section on 
Paediatrics, November, 1889. 2 
JACOBI, 
mained at present to be said upon the subject. 
Nevertheless, as various considerations have sug- 
gested themselves to me during observations of the 
case I am about to relate, I take the liberty of laying 
them before the profession. 
A little boy, four years of age, was brought to 
my office in September, with a history of five weeks’ 
febrile sickness, which had been considered by one 
physician to be a malarial fever; by another, ty- 
phoid. For some time the fever had been of a 
hectic type, coming on only in the afternoon. On 
the occasion of the first visit, which was in the 
morning, the temperature was normal. The child 
■was excessively pale, with a suggestion of oedema in 
the face, but not elsewhere. The respiration was 
not accelerated, and cough had been so slight as not 
to be mentioned by the mother until after I had in- 
quired concerning it. Inspection of the chest, how- 
ever, at once suggested thoracic trouble, for the 
anterior portion was markedly arched forward, the 
arching being equally prominent over the left side 
and over the sternum, and not much less over the 
right side. The mother had noticed that the chest 
was—as she expressed it—swollen. There was some 
dilatation, of the veins over the sternum. On the 
left side, absolute percussion dulness extended 
from the second rib over the whole anterior region 
of the chest and reached the right border of the 
sternum. Above this zone of absolute dulness, a 
zone of relative dulness extended to the apex. 
Posteriorly, dulness extended from the spine of 
the scapula to the base of the lung. Over the REMARKS UPON EMPYEMA. 
3 
region of absolute dulness, breath sounds were en- 
tirely absent. There was no tubular breathing. 
From the age and fretfulness of the child, it was 
impossible to obtain whispering pectoriloquy— 
which is said to be present in serous effusion, absent 
in empyema, and to constitute a valuable means of 
diagnosis between them. Above the region of ab- 
solute dulness, on the left side, both before and 
behind, existed tubular breathing; right lung was 
normal. The apex of the heart pulsated in the 
epigastrium. 
I regret that cytometer measurements of the chest 
were not made at this time. Nor was it noticed 
whether the liver was displaced, through compres- 
sion and compensatory longitudinal enlargement of 
the right lung. 
The assemblage of signs and symptoms just enu- 
merated sufficed to justify an almost positive diag- 
nosis of a purulent effusion in the left pleura, suffi- 
ciently abundant to displace the mediastinum consid- 
erably to the right side. An exploratory aspiration 
was deferred until the moment for operation, which 
was appointed for the afternoon of the same day. 
At this time the hypodermic needle, inserted pain- 
lessly -after previous application of ice and salt, 
withdrew a syringeful of pus. 
In saying that anterior mediastinum was dis- 
placed, I have used the current expression, but have 
not used it in regard to the heart, which was found 
beating in the epigastrium, and which would usually 
be said to be pushed over. According to the argu- 4 
JACOBI, 
ments and demonstrations of Douglas Powell,1 of 
London, Peyrot,2 of Paris, and Garland,3 of Boston, 
the displacement of the heart in pleural effusion s not 
due to pressure of the fluid on the diseased side, but to 
aspiration of the lung on the sound side of the chest. 
“The mediastinum,” observed Dr. Powell in 1869, 
“ is poised by the contending elasticities of the two 
lungs.” The lungs exercise a traction power on the 
mediastinum, and also on the thoracic walls. The 
latter have been shown by an experiment of Dr. 
Salter’s, repeated by Dr. Powrell, to move out- 
ward about y-J-g- of an inch when air was admitted 
into the pleural cavity after death. This shows that 
during life, and while the lungs were expanded, they 
were habitually drawing the thoracic walls inward, 
by virtue of their elasticity. When the lungs col- 
lapsed, by the admission of air into the pleura, this 
traction ceased, and the thoracic walls moved out- 
ward to an extent corresponding to the previous 
retraction. The same degree of traction must 
necessarily be exerted on all parts of the pleural 
cavity, hence upon the mediastinal walls as well 
as on the thoracic. But as both lungs exercise 
the same pressure, each, normally, neutralizes the 
influence of the other, and the heart remains poised 
or suspended from the attachments of its great 
vessels, between two equal opposing forces. 
If, now, the elastic traction of one lung dimin- 
1 British Medical Journal, 1869. 
2 Archives G6n. de Med., 1876. 
3 Boston Med. and Surg. Journ., 1878, and monograph. REMARKS UPON EMPYEMA. 
5 
ishes, the power of the other lung is proportionately 
increased, and the mediastinum, with the heart con- 
tained in it, is accordingly drawn to that side. 
Dr. Powell points out that it is only in this way 
that we can explain the displacement of the heart in 
the presence of a very moderate degree of effusion. 
An important corollary to the same proposition is, 
that cardiac displacement is not to be held to indi- 
cate a very large amount of effusion. On the con- 
trary, it is one of the earliest symptoms, and observ- 
able while the effusion is yet quite small. 
Dr. Garland, in his most ingenious monograph on 
Pneumono-dynamics,1 quotes Skoda as expressing 
the same opinion on the cause of cardiac displace- 
ment. Nevertheless, it is unquestionable that the 
majority of writers continue to speak of the dis- 
placement of the heart by pressure of the effusion. 
It is easy to verify by experiment Dr. Powell’s 
statement—that cardiac displacement occurs with 
very small effusions, and soon after they are poured 
out. Indeed, in the experiment, where the effusion 
is necessarily sudden, the displacement is equally 
sudden. Thus, in an etherized dog, having ascer- 
tained that the cardiac apex was in its normal posi- 
tion, I injected—through a glass canula, fitting air- 
tight—seventy-five cubic centimetres of warm water 
into the left pleural cavity at the anterior axillary line, 
and in the seventh intercostal space. Three minutes 
later the heart was found to be visibly and forcibly 
pulsating at the right of the sternum. A respiratory 
1 Pneumono-dynamics : Boston, 1878. 6 
JACOBI, 
tracing taken immediately, with a tambour placed 
over the right side of the chest, shows a great ampli- 
fication of the respiratory excursion, both in inspira- 
tion and expiration. 
Tracing No. 1 contains (A) a normal tracing 
taken before any operation, and (£) a tracing taken 
immediately after plunging one arm of a fine glass 
T-tube into the left pleural cavity. 
A- 
B 
In this experiment the tissues were incised down 
to the internal intercostal muscles and the glass 
tube plunged into the pleura. The facility with 
which this can be done shows the rapidity with 
which the lung retracts with its visceral pleura, so 
that the virtual cavity is instantaneously converted 
into an actual one. Were not this the case, it would 
be almost impossible to open the pleura without 
wounding the lung. The following tracing shows 
the effect on respiration of opening the pleura in 
the way described—the inspiration on the uninjured 
side becomes more ample, as is seen in tracing 
No. 3. REMARKS UPON EMPYEMA. 
7 
The fourth tracing, taken after injection of seventy- 
five centimetres of warm water, shows that this am- 
plitude is still further increased. 
As Dr. Douglas Powell remarks, the heart is so 
movable that its displacements may serve as a most 
delicate and accurate measure of any perturbation 
in the normal intra-thoracic equilibrium of forces— 
that is, of balancing tractions. It is interesting to 
notice that while a diminution in the elastic trac- 
tion of the lung, which coincides with a pleural 
effusion, allows the heart to be displaced—i. e., 
drawn over to the opposite side—diminution of 
elasticity due to solidification and diminution of 
size, as when lung tissue collapses over an empty cav- 
ern, is followed by displacement of the heart toward 
the affected side, so that marked lateral and upward 
displacement of the heart is an important sign of 
contraction of pulmonary caverns, and, to a consider- 
able extent, measures their rate of progress to heal- 
ing. But in this case the heart fo’lows the negative 
pressure determined by the potential vacuum which 
exists, when the lung tissue tends to retract from 
the thoracic wall. When there is a pleural effusion 
there is no potential vacuum, for the fluid com- 
pletely fills all the space left by the retracting lung, 
and the amount of fluid and amount of pulmonary 
retraction are necessarily exactly proportioned to 
each other. It is only in this sense that the fluid 8 
JACOBI, 
can be said to favor directly the cardiac displace- 
ment. Its principal effect is indirect, and exerted 
through the lung, which, in presence of the fluid, 
loses a portion of its power of elastic traction. 
This last remark brings me to another very inter- 
esting and much debated problem of pleural effu- 
sions, namely, the precise effect exercised on the 
lung by the fluid in the pleura. 
The same line of thought which leads to the view 
that the heart is displaced by pressure, sustains the 
current theory that the lung is “compressed” by 
the effused fluid. Indeed this theory is habitually 
taken as a matter of course, and as not needing dis- 
cussion. Nevertheless, as soon as we begin to re- 
flect on the nature of the lungs, and of the forces 
which maintain them expanded in the thoracic 
cavity, it seems to me remarkable that the true view 
of the case should have remained so long undiscov- 
ered. The first demonstration of this view that I 
have read, was given by Dr. Garland, of Boston, 
in 1878, and is admiringly adopted by Dr. Douglas 
Powell. This view reposes upon obvious theoret- 
ical considerations; upon the results of experi- 
ments with inflated balloons in glass vessels, where 
the physical conditions of pleural effusions are 
imitated with surprising accuracy; finally, upon 
the results of injections into the pleural cavity of 
dogs made with fluids capable of solidification, and 
which form permanent moulds in situ, and thus in- 
dicate the course taken by the injection in the fluid 
state. 
The theoretical consideration is that the lungs are REMARKS UPON EMPYEMA. 
9 
highly elastic bodies, normally maintained in a 
state of extreme tension by the pressure of the air 
contained in them, and which, while the pleural 
surfaces remain in contact, is counteracted by no- 
thing. The atmospheric pressure hence acts with 
full force, and keeps the lungs exactly applied to 
the walls of their containing cavity, except in the 
complemental space at the base, reserved for forced 
inspiration. But if either air or liquid be admitted 
into the pleura, the internal atmospheric pressure 
within the pulmonary cavities, the bronchi, and air- 
cells, is counteracted to an exactly proportionate 
extent. To the same extent to which the pressure 
of the air is diminished, is the elastic tissue of the 
lung able to return from the over-stretched condi- 
tions into which it had been put by the unopposed 
pressure of the air. Like any other elastic body, 
the lung tends to return to its original size as soon 
as the distending force is withdrawn. In the case 
in question, the distending force is not withdrawn, 
but it is partially neutralized. To the same extent 
does the elasticity or retractility of the lung come 
into play : it retracts upon its contained air. 
As in every interplay of physical forces, the effec- 
tive condition of this phenomenon, the retraction 
of the lung, cannot be considered its efficient cause. 
The effusion does not precede in time the retrac- 
tion ; but the two phenomena march pari passu to- 
gether. The efficient cause of the retraction of the 
lung is the elasticity of its tissue, which comes into 
play as soon as the obstacles to its manifestation are 
removed. The effusion removes the obstacle by 10 
JACOBI, 
neutralizing to a greater or less extent the pressure 
of the air. It is, therefore, the condition upon 
which the manifestation of the retractile power of 
the lung depends; but by no means the efficient 
cause of the retraction or of the diminution of size. 
An elastic body cannot be compressed until its 
elasticity is exhausted. 
So long as any elasticity remains, the body exer- 
cising pressure can only neutralize atmospheric 
pressure, and allow the over-stretched elastic body 
to return upon itself. The pressure allows this; it 
does not compel the reduction of the body to a 
small size, as is done when inelastic bodies are 
compressed, by forcible approximation of their 
molecules. 
This theoretical exposition is well illustrated 
by Garland, by means of such a little apparatus 
as is here shown. It consists of a pear-shaped 
flask, surmounted by an opening closed with a 
rubber cork, and terminating below in a long tube, 
through which passes a stop-cock. Within the 
flask is suspended a thin rubber balloon, attached to 
a glass tube, which passes air-tight through the 
rubber cork. The stop-cock and tube at the lower 
part of the flask are filled with water, by immersing 
the tube in water to above the level of the stop-cock, 
while the cork is out of the flask. The tube is then 
plunged under water, the stop-cock opened, the 
cork inserted tightly, and the balloon inflated 
through the glass tube until it fills the flask. If the 
size of the balloon and the flask corresponded accu- REMARKS UPON EMPYEMA. 
11 
rately, the balloon would adapt itself accurately to 
the walls of the flask. As it is, the adaptation is 
Fig. i. 
Balloon around glass rod, before insertion into flask. 
exact enough to fulfil the conditions of the experi- 
ment. See Fig. 2. 12 
JACOBI, 
The stop-cock may then be closed and the appa- 
ratus be lifted out of the water without causing any 
change. The balloon remains inflated, for, though 
its cavity communicates freely with the open air, the 
Fig. 2. 
Flask with balloon expanded and filling flask. Tube filled with 
water, and then closed. 
column of water remains in the lower tube. If now, 
while this lower tube is plunged to a greater or less 
extent under water, the stop cock be opened, the 
column of water in the tube will be subjected to the REMARKS UPON EMPYEMA. 
13 
pressure of the water in the vessel—pressure which 
increases with the depth of immersion. At a certain 
depth there will be no change, for the column of 
Fig. 3. 
Flask after some water has been admitted by turning the stop- 
cock while nozzle under water. Balloon retreated and partly col- 
lapsed. 
water below the balloon will be equal to the pres- 
sure of the atmospheric air within. If the tube 
be plunged lower, the pressure of the column of 14 
JACOBI, 
water will become equivalent to a part of the pres- 
sure of the air, and will neutralize it. To exactly 
the same extent will the balloon be relieved of a 
certain degree of tension, and return upon itself 
proportionately. Thus, as Garland expresses it, the 
“balloon flees before the advancing column of 
water,” and must continue to do so until its re- 
tractility is exhausted, and the flask is exactly filled 
by water plus the collapsed balloon. In this condition 
it would be impossible to aspire water into the flask, 
as had previously been done while the balloon was 
retracting and exerting a negative pressure upon the 
column of water. But if more water were injected 
forcibly into the full flask—as it could, make no 
room for itself against the rigid walls—it would, 
with a point d'appui taken upon them, press upon 
the balloon until the compressibility as well as the 
elasticity of the latter was exhausted. The same 
thing may happen with pleural effusions, but only 
under one of two circumstances. The effusion may 
be exceptionally abundant, or the lung may have 
been already consolidated by disease, and thus, at 
the outset, deprived of its elasticity, and, therefore, 
exposed to compression much earlier in the course 
of an effusion. 
Observation of this simple but instructive appa- 
ratus illustrates some other circumstances. As the 
balloon retracts, returning upon itself from the con- 
dition of over-distention, it becomes flaccid. It is to 
an analogous flaccidity of the lung that Weil has 
attributed the phenomenon of tympanitic percussion REMARKS UPON EMPYEMA. 
15 
resonance often heard over the lung above the level 
of a pleural effusion. 
The stomach, whose walls are flaccid, gives a tym- 
panitic resonance which, as every one knows, con- 
trasts markedly with the much lower percussion 
note of the normally distended lung. It is easy to 
demonstrate experimentally, as I have myself done 
before a class, by inflating the excised lung of a calf 
or sheep, that, when inflation was complete, percus- 
sion yielded the normal tone ; but if air was allowed 
to escape from the lung, percussion gave a tympanitic 
sound. According to Weil, in the distended lung 
the walls of the air-cells do not vibrate with the 
vibrations of their contained air ; but in the relaxed 
lung, as in the stomach and intestine, the walls of 
cavities containing air are thrown into vibrations 
whenever the air vibrates ; and the coincident vibra- 
tions of heterogeneous bodies result in the tym- 
panitic sound. 
Another point deserving notice in the apparatus 
is the reexpansion of the balloon if water be al- 
lowed to run out through the inferior opening. 
The balloon reexpands as rapidly as it had re- 
tracted. It is drawn by the negative pressure of 
the water potentially; the efficient cause of the 
reexpansion being the pressure of the internal air, 
when a tendency exists to form a vacuum, as the 
water falls away from the balloon. This phenome- 
non is of great importance in understanding the 
reexpansion of the lung after operations for the 
removal of a pleural effusion. I will return to it 
again. In describing the condition of the child 16 
JACOBI, 
previous to operation, I have said that the region 
of absolute dulness reached the second rib in front 
and the spine of the scapula behind, and was 
bounded superiorly by a horizontal line. There 
did not exist the curved, or letter S line, discovered 
and described by Dr. Ellis, of Boston. According 
to this line, the region of absolute dulness is highest 
in the axillary line, and thence descends toward the 
median line, to the sternum in front, to the vertebral 
column behind. Dr. Peter, of Paris, interpreted 
this line as an indication of a purulent effusion, 
which, being more viscid than a serous fluid, would 
adhere in places to the thoracic walls, while the 
serous fluid would assume the hydrostatic level. It 
is unnecessary to discuss this theory, for it has been 
abundantly proved that the curved line can be dis- 
tinguished by careful percussion when the effusion is 
serous as well as when it is purulent. But Garland, in 
seeking to explain the rationale of this elevation of 
the fluid in the axillary line, has ingeniously demon- 
strated the value of the curved line as a measure of 
the remaining retractility of the lung—as a measure 
consequently of the amount of effusion. 
Since the elevation of one part of the upper sur- 
face of a mass of liquid is contrary to hydrostatic 
laws, it is clear that these must have been thwarted 
by some special force acting in opposition to them. 
Fluid cannot rise above its own level, and if it 
is found above it, it must have been driven or 
pushed up. Now it has already been shown, and 
elegantly illustrated by the balloon and flask appa- 
ratus, that during the early stages of a pleural efifu- REMARKS UPON EMPYEMA. 
17 
sion, while the lung is retracting, it necessarily 
aspires the fluid in contact with it, by virtue of neg- 
ative pressure. The force of retraction is greatest 
where the extension has been greatest, hence first 
and most powerfully exercised from below upward. 
Subsequently, the lung also begins to retract in its 
transverse diameter, or from the external thoracic 
wall toward the lung root. In so retracting, a 
virtual vacuum is created between the lung and the 
chest wall, and into this the fluid rises. It rises first 
and higher in the axillary line, because the force of 
retraction is greater in the transverse diameter of the 
lung than antero-posteriorly. Correlatively, as long 
as the region of absolute dulness is confined to the 
inferior and axillary portions of the chest, and the 
diaphragm is not depressed,' we may infer that the 
effusion is moderate, and that the lung retains much 
retractile, hence much expansile, power. Even 
when absolute dulness has spread over the anterior 
and posterior regions of the chest, the fluid may be 
known to have followed the lung, so long as its 
upper border presents a curved line. But if the 
lung reaches its furthest limit of retraction, it ceases 
to aspire the fluid, or to hold this above its normal 
level, which is a horizontal line. 
Contrary, therefore, to the theory of Peter, the 
maintenance of the curved line, incapable of dis- 
tinguishing the nature of the fluid, does indicate 
moderation in its amount, and preservation of good 
retractile power in the lung; while the substitution 
of a straight line, indicating the natural level of the 18 
JACOBI, 
fluid, shows that the effusion is extensive, and the 
lung on the point of being compressed. 
Garland tested the respiratory force of the lung 
by means of injections, into a dog’s pleura, of 
cocoa butter, which was allowed to remain there 
until complete solidification. Examination of the 
moulds thus formed showed that, whether the in- 
jection had been made with the dog in a horizontal 
position or suspended vertically, the fluid had risen 
above its hydrostatic level, and formed a curved line 
projecting toward the axilla. I have imitated this 
experiment and obtained similar, though less striking, 
results, as the amount of cocoa butter injected was 
smaller. 
The little boy, whose case forms the text of this 
paper, as soon as the diagnosis of empyema had 
been confirmed by the hypodermic syringe, was 
■etherized, laid upon the affected side, and an in- 
cision made in the eighth intercostal space in the 
posterior axillary line. The operation was rendered 
a little more difficult by the position given to the 
child. But this inconvenience was held to be com- 
pensated by the advantage of securing to the sound 
lung entire freedom from compression. The incision 
through the skin was a little less than an inch in 
length, and was made layer by layer until the pleura 
was nearly reached, when a trocar was plunged in, 
and its opening subsequently enlarged until it would 
admit a drainage-tube the size of my finger. This 
could just be squeezed through the space between REMARKS UPON EMPYEMA. 
19 
the ribs, which, as always in a young child, was 
narrow. 
On account of this narrowness, which has fre- 
quently been recognized as a source of difficulty, it 
did not seem that anything would be gained by 
making a longer incision, unless, as in Dr. Cabot’s 
method, two drainage-tubes were to be inserted. 
The size of the opening which should be made in 
the chest, in order to evacuate a purulent effusion, 
has been the subject of animated controversy. 
It seems scarcely necessary to reopen the discus- 
sion in regard to aspiration of the chest in em- 
pyema. The discussion of the New York Academy 
of Medicine, held in 1887, resulted in the unequiv- 
ocal condemnation of aspiration for purulent effu- 
sion, and in the recommendation of antiseptic in- 
cision as a method which, as Dr. Holt remarked, 
has changed empyema in children from being one 
of the most fatal to one of the most amenable 
of diseases. But it is both interesting and sur- 
prising to note how very recently this method has 
been definitely acquired. Guibert, in 1875,1 relates 
with complacency the case of a boy of eleven, under 
treatment for nine months, and subjected to seventy- 
four punctures with Dieulafoy’s aspirator. In 1862 
Ziemssen, quoted by Schenks, said that operation 
was rarely needed for empyema in children. In 
the great majority of cases in which aspiration has 
been tried, the continued recurrence and aggra- 
vation of all morbid conditions decided the phy- 
1 Lyon Medical, November, 1875, quoted by Bouveret. 20 
JACOBI, 
sicians to resort to incision, with drainage. Dr. 
Holt has collected 121 cases treated by aspiration, 
of which 6 died; 23, or nineteen per cent., were 
cured ; the rest came to treatment by incision. Yet 
in the International Congress of 1881, although 
Ranke and Gerhardt advocated free incision, Bag- 
insky advised delay, to see if the pus might not 
be removed by expectoration. Robert Lee and 
Parker, of London, advocated repeated aspiration, 
and Dr. Jacobi reported three cases of empyema 
in children, observed in one year, who had been 
radically cured by aspiration.1 
1 Esch, N. Y. Med. Record, 1887, relates a case of empyema in 
a boy eight years old. Twelve ounces of pus were withdrawn 
from the pleura by aspiration, and, after a temporary improve- 
ment, the refilling of the chest necessitated repetition of the aspi- 
ration seven times in the course of a few weeks. Each time, eight 
to fourteen ounces of pus were withdrawn. The child had chills, 
and a temperature ranging from 1020 to 104°. Finally, Esch 
injected through the aspirating needle eight ounces of a two per 
cent, solution of biborate of soda, and withdrew in ten minutes. 
Speedy recovery. 
Leichtenstern, in Gerhardt’s Cyclopaedia, says that it is unques- 
tionable that empyema may be cured by repeated puncture and 
aspiration, like any other abscess. In 1871, Bouchert (Gaz. des 
Hop., 1871) proposed to treat infantile empyema exclusively by 
this method. 
Branthomme’s thesis contains eighteen cases cured by single 
aspiration. 
Bouveret quotes forty-three from the thesis of Branthomme, di- 
vided into four groups. In the first group of 18 cases, a single aspira- 
tion sufficed to cure. In the second group of 11 cases, the aspiration 
was practised twice—-the recovery equally prompt. In the third 
group of 3 cases, there were three aspirations, and speedy re- 
covery. Finally, in a fourth group of 11 cases the number ot 
aspirations ranged from 6 to 122. REMARKS UPON EMPYEMA. 
21 
Some years ago I treated by aspiration a case of 
empyema in a child of eighteen months, and the 
child died.1 The dangers of aspiration are not 
purely negative and dependent on delay in reliev- 
ing the organism of its collection of pus, and lungs 
and heart of the mechanical impediments offered to 
their functions; but, unless the disinfection of the 
aspirating needle is perfect, and it often is not, there 
is the same danger in plunging it into a closed 
pleural effusion as has been so often noted in the 
hypodermic exploration or aspiration of abdominal 
cysts, and of which I have myself reported two ob- 
servations. If germs are carried into a cavity with 
a free opening, and from which a current of fluid is 
constantly flowing, they have at least a large pro- 
portion of chances of being washed away. But, 
introduced into an hermetically closed cavity, no 
such chance is offered, and infection is unavoidable. 
This danger does not seem to have been emphasized 
by authorities as distinctly as the fact of the almost 
inevitable recurrence of the effusion after the most 
complete aspiration, and the great probability that 
the aspiration in every case must remain incomplete. 
Other more exceptional dangers of aspiration, em- 
pyema shares in common with serous effusions; the 
dangers of albuminous expectoration, pulmonary 
1 Schenker (Jahrb. fiirkinderheilk., N. F., 1883, Bd. xx.) relates 
fifteen cases, of which six were treated at first by aspiration. Of 
these one died after a second aspiration. The others were 
treated by incision and drainage. 
Goodhart (Guy’s Hosp. Rep., 1877) reports two cases of aspi- 
ration, both of whom died. 22 
JACOBI, 
oedema, and other accidents liable to occur when 
a lung, bound down by adhesions, is drawn upon 
by a powerful aspirating machine. These dangers 
are, of course, more rare in children, precisely be- 
cause in them the lung is usually movable. The 
prejudice in favor of aspiration dates from the epoch 
when incisions were made without any antiseptic 
precautions. We now know that many of the dan- 
gers then attributed to the introduction of air were 
really due to infection of the wound or of the sup- 
purating cavity. But it is again surprising how 
recent is this discovery, and indeed how long a time 
elapsed after the establishment of the Lister method 
elsewhere, before it was applied to the treatment of 
empyema: according to Bouveret,1 the very first case 
in which pleurotomy was performed for empyema 
with antiseptic precautions occurred in Calcutta, 
under the care of an English surgeon, Ewart, and 
was reported by him in 1873.2 1877, Goodhart 
speaks despairingly of the conflict of opinion in 
regard to the treatment of empyema; says that the 
incision treatment gives a mortality of 33 per cent., 
and is not more favorable than Playfair’s method of 
subaqueous drainage.. “This,” he observes, “issim- 
plicity itself, and looks, at first sight, almost perfect. 
I do not know that even now I am prepared to say 
that any other method of treating empyema is 
better, but, after treating several cases and seeing 
others treated, I think if no other treatment can be 
1 Traite de l’Empyeme, 1888, Paris et Lyon. 
2 Lancet, 1873. REMARKS UPON EMPYEMA. 
23 
made to give better results than it, empyema will 
remain a most fatal disease, with the chances for or 
against the patient’s life about even.” 1 
In 1880, Dr. Cabot commented on the slow pro- 
gress made by the antiseptic method in regard to 
the treatment of empyema, and attributed it in part 
to the tenacious belief of physicians that in aspira- 
tion they have a means of curing the patient with 
less risk, hence do not trouble themselves to master 
the methods by which incision may be stripped of 
its risks. At this date Dr. Cabot could find reports 
of but ten cases treated antiseptically, all in Ger- 
man ; namely, four by Wagner,2 four by Goeschel,3 
and two by Krabbel. 
To-day, the cases of antiseptic pleurotomy have 
multiplied so considerably, that it would be useless 
to quote them in a paper like the present. I will 
again, therefore, simply refer to Dr. Holt’s statistics 
of 63 cases, with 61 recoveries and 2 deaths. The 
statistics of Cabot and Eddison, reproduced in 1888 
by Bouveret, of 40 cases of non-tuberculous em- 
pyema in adults, give 34 complete cures, 2 perma- 
nent fistulse and 4 deaths.4 The case which 
1 Loc. cit. 
2 Volkmann’s klinische Sammlung, No. 197. Also Berlin, klin. 
Wochen., 1878. 
3 Berlin, klin. Wochen., 1878. 
4 Among reported cases of successful pleurotomy may be cited : 
Goeschel: Loc. cit., four cases, four recoveries (young chil- 
dren). 
Phelps (N. Y. Record, 1880): fourteen mixed cases, eleven re- 
coveries, three deaths. 24 
JACOBI, 
forms the basis of this paper is the sixth I have 
treated, and with success. My friend Dr. Annie 
Daniel also reports six cases where antiseptic drain- 
age treatment was followed by complete recovery. 
There can be no doubt, therefore, that the pendu- 
lum of chances has swung over so considerably 
during the last decade, that, with incision and 
drainage treatment, recovery of children from em- 
pyema should be considered the rule—death the ex- 
ception. 
There are, however, four details of the treatment 
that are not so well settled. These are, the use of 
the spray, the size of the opening to be made in the 
chest wall, if puncture and aspiration be excluded; 
the employment of irrigations, and the use of a 
valve in the dressing. When, in 1873, ar away in 
Calcutta, the antiseptic method was, as it would 
appear, first applied to the empyema operation, the 
incision and subsequent dressings were rigorously 
guarded by the spray. For a long time the spray 
was considered indispensable; and as late as 1888, 
Bouveret, while admitting the superfluity of the 
spray for other surgical operations, insists upon re- 
Lindner: Jahrb. fur kinderkrank., N. F., Bd. xvii., one case 
recovered—seven months' child. 
Skerritt vBrit. Med. Journ., 1876): one case, recovered. 
Cabot (N. Y. Med. Journ , 1880) : seven cases, children, all 
recovered rapidly. 
Redenbacher (Deutsch. Archiv. fur klin. Medicin, Bd. ix.) • one 
case, recovery in fourteen days. 
Huber (Archives of Paediatrics, Nov. 1889) : two cases, double 
empyema, recovery. REMARKS UPON EMPYEMA. 
25 
taining it in treatment of empyema. The spray 
was used by Skerritt1 in 1876, by Koenig and Wag- 
ner in 1878,2 but the latter does not consider it 
necessary, and the former claims always to resect a 
rib. The spray is uniformly advised by Douglas 
Powell,3 and by Bennett in Ashhurst’s Cyclopedia of 
Surgery. It was strenuously insisted upon by Dr. 
Cabot in 1880,4 by Leamoine in 1880, and is ad- 
vised by Donaldson, writing in Pepper’s System of 
Medicine, whenever an incision is made six centi- 
metres long. It is considered superfluous if the in- 
cision only passes through the skin and muscles, and 
the pleura itself is opened by a trocar. In the 
Academy discussion of 1887, Dr. Abbe advised the 
spray, but this was not mentioned by any other 
speaker, nor in the discussion at Washington last 
September over Dr. Huber’s two remarkable cases 
of double empyema. Dr. Gerster, in his treatise on 
antiseptic surgery, expressly condemns the spray as 
an objectionable feature for empyema as for other 
operations. 
In the case of the little boy here described, no 
spray was used, and recovery was complete—i. e., 
the tube was withdrawn on the thirty-second day. 
In my five other cases, however, the duration of 
1 Brit. Med. Journ., 1876. 
2 Berliner klin. Wochensch., 1878. 
3 Diseases of Lungs and Pleura. 
4 N. Y. Med. Journ., 1880. See also Neurbe-Fraentzel, in 
Ziemssen. 
The spray was used in all the forty-one cases, including four- 
teen cases of children, in the statistics compiled by Bouveret. 26 
JACOBI, 
treatment was about two months. In Dr. Daniel’s 
six cases the spray was also omitted, but other 
antiseptic precautions were used. The 
drainage-tube employed had been kept in pure 
carbolic acid during the twenty-four hours preced- 
ing the operation. 
Of these six cases one died suddenly on the 
third day, tw7enty-four hours after an erysipelatous 
inflammation around the wound had been noted. 
In the five other cases the tube was removed on the 
thirteenth, nineteenth, twenty-third, twrenty-eighth, 
and thirty-third days respectively. 
While the fluid is running out from the incised 
chest no air can enter. The entrance of air is sig- 
nalized by a loud suction noise, and takes place at 
the moment that the abnormal positive tension in 
the pleural cavity, due to the presence of the fluid, 
is changed to a negative tension by its evacuation. 
It is quite possible, if the contents be perfectly fluid, 
to place a thick layer of antiseptic gauze over the 
opening at the moment the flow begins to slacken. 
By this means any air drawn into the chest will be 
filtered. This would even be possible when, through 
a large opening, semi-solid masses of fibrin and clots 
were being being expelled by coughing. 
It is generally admitted now that infection of 
wounds does not proceed from germs floating in the 
air, but attached to instruments and other solid 
bodies. Further, the experiments of Stimson, con- 
firmed by Cabot himself, who so strenuously recom- 
mends the spray, show that air which has passed 
through spray continues to infect culture tubes; on REMARKS UPON EMPYEMA. 
27 
the other hand, methods of operation which effectu- 
ally exclude air, as the subaqueous drainage, and the 
guarded trocar of Reybaud, were very often followed 
by fever and other signs of sepsis, often fatal. On 
one day when I operated by the trocar on a child at 
the Mount Sir.ai Dispensary, another child of the 
same age was admitted to the wards and submitted 
to subaqueous drainage. The dispensary case, though 
brought from a distance three times a week, recov- 
ered, after some vicissitudes, in two months. The 
hospital case died of exhaustion after three. 
In cases where air has been thoroughly excluded 
from the pleura opportunity remains for infection of 
the external wound; and this opportunity recurs 
with every change of the dressings. Constant irri- 
gation of the lips of the wound during the dressing 
is a much more potent method of averting infection 
than is the spray. 
The size of the incision seems to have been regu- 
lated according as the operators were more preoccu- 
pied with freeing the pleural cavity from pus, or 
with facilitating the reexpansion of the collapsed 
lung. It is under the influence of the first idea that 
Konig and Demme have advised the resection of a 
rib for, at least, all adult cases ; that directions are 
given for incisions six centimetres long, and that 
stress is laid upon placing the incision as low as 
possible. Certainly, for children at least, too many 
cases are now on record of cure by simple incision 
to allow us to consider resection as anything but an 
exceptional expedient. Further, so long as the con- 
tents of the pleura are entirely fluid, it is difficult to 28 
JACOBI, 
see why they will be evacuated any more easily 
through an opening of six centimetres than through 
a tube the thickness of a finger. The tube is only 
inadequate if there are solid coagula too large to pass 
easily through it. Similarly, it seems to me extremely 
doubtful whether the situation of the tube at a lower 
portion of the chest is more favorable to the outflow 
than a higher position. In a case of empyema 
that I saw in consultation with Dr. Daniel, the 
pointing was under the right clavicle, and here 
the opening was made. Drainage was perfect; and 
this is always the experience with spontaneous open- 
ings of empyema. The fact that these openings 
occur in the upper parts of the chest at least as often 
as lower down, is itself a proof that the contents of 
the pleural cavity may be pushed toward any point 
on the circumference, and do not follow the laws of 
gravity. The familiar experience of the straight 
glass drainage-tube which is so often plunged into 
the peritoneal cavity after laparotomy operations, 
shows that the pressure of the closed cavities of the 
living body is capable of forcing fluids upward as 
well as downward. In the empyema operations the 
perforated drainage-tube generally passes upward; 
it certainly did so in the case of Frank. But the 
circumstance did in nowise interfere with the drain- 
age. 
The forces which expel the fluid from the pleura 
are: i. The positive tension existing in the cavity, 
and which, to the great detriment of the patient, has 
replaced the negative tension which is normal. 2. 
The reexpansion of the lung, which should begin as REMARKS UPON EMPYEMA. 
29 
soon as this positive tension is lessened. This is 
illustrated in the balloon and flask. 3. The respira- 
tory movements—those of inspiration as well as those 
of expiration. During inspiration, when the chest- 
wall moves outward and enlarges the pleural cavity, 
all the contents of the cavity must move forward in 
the direction of the least resistance. Unless the 
opening be occluded, the lung will not so move, 
because the internal atmospheric pressure which 
should keep out the walls of its cavities, is neu- 
tralized by air on the other side, and is, therefore, 
inoperative. But if there be fluid in the cavity, its 
pressure exceeds both that of the air within and of 
the air without; and when compelled to move, it 
moves forward toward the point of least resistance— 
i. e., the fistulous opening toward the external air. 
For these reasons it is difficult to see any advan- 
tage in a very large opening; provided, of course, 
that the flow of liquid continues perfectly unob- 
structed. 
The gradual contraction of the pus cavity, effected 
through the approximation of the pleural surfaces, 
can hardly be counted among the expelling forces. 
Certainly a most important condition for the forma- 
tion of such adhesion is the persistent evacuation of 
the pus as fast as it forms. In the case of Frank, as 
the flow of pus through the canula began to slacken, 
an antiseptic pad was laid over the opening—not, 
however, before air was twice drawn into the pleura 
with the usual suction noise. The respiration was 
considerably accelerated at the moment of opening 
the pleura, and for some moments afterward, the 30 
JACOBI, 
inspiration becoming deeper. The same change in 
respirations is observed when a closed tube, com- 
municating only with a manometer, is plunged into 
the healthy pleura of a dog. The change seems due 
entirely to the greater exertions made by the sound 
lung, but implies a direct transmission of impressions 
from the wounded pleura to the inspiratory centre in 
the medulla. 
In the boy Frank the opening made by the trocar 
was enlarged by the bistoury until it would easily 
admit the drainage-tube; this was inserted, and 
secured by a safety-pin packed around with iodo- 
form gauze, after the lips of the wound had been 
thickly powdered with iodoform, and while the pus 
was still running from the tube, an antiseptic dress- 
ing was applied without previous irrigation of the 
pleural cavity. 
The question of irrigations into the pus cavity— 
primary or consecutive—has been strenuously de- 
bated. When advised, it is with the intention: i. 
Of thoroughly removing all pus from the pleura, so 
that none may remain to decompose. 2. Of disin- 
fecting the pleural cavity of germs which, in spite 
of all previous precautions, may have been carried 
into it. 
Now this second reason can have no weight, if 
the antiseptic precautions previously taken have 
any real efficiency. As to the first reason, the 
records of cases prove that pus reaccumulates in the 
twenty-four or forty-eight hours following the opera- 
tion in amount sufficient to necessitate a change of 
the dressings, and this, whether irrigation has been REMARKS UPON EMPYEMA. 
31 
practised or not. Nevertheless, many of the writers 
who use primary irrigation, as Cabot, do not repeat 
the washing on account of this reaccumulation, but 
simply renew the dressings. If the irrigation be not 
needed the second time, it is difficult to see why, 
for the purpose of removing the pus, it should be 
required the first time. 
The amount of pus that is poured out in the first 
day or two after the operation is often astonishing. 
In the case of Frank—where, at the first dressing, 
thick layers of cotton wool were used instead of, as 
subsequently, oakum—the dressing, clothes and even 
bedding were saturated. It is true the evacuation of 
pus had not been quite complete at the operation ; but 
there could not have been much fluid in the pleura, 
for, before applying the dressing, I ascertained that 
almost normal percussion resonance extended all 
over the back of the chest. The abundant dis- 
charge, therefore, of the first day must have been 
due to a new formation or effusion of pus; and it 
is comprehensible that the removal of pressure from 
the pleural surfaces may facilitate an abundant emi- 
gration of leucocytes from the distended capillaries 
and lymph spaces of the pleural tissue. 
In a perfectly normal progress of events, when 
the later or secondary elimination has been effected, 
the discharge from the drainage-tube should rapidly 
diminish and cease. Bouveret relates one case of 
complete cure in nine days, the shortest on record. 
Many cases are on record where the tube could be 
removed in twenty or fifteen days, or even less. 
In Ewart’s pioneer case, an adult, the discharge 32 
JACOBI, 
is said to have become serous in six days. Two 
circumstances thwart this normal progress: the 
suppurating surface may become infected, or the 
pleural inflammation which gave rise to the suppura- 
tion may persist as suppurative, instead of retrograd- 
ing to an adhesive form. In either case, the child 
will have fever, and the discharge will remain offen- 
sive. In either case, irrigation becomes indicated, 
and, if practised, will be followed by a fall of tem- 
perature. 
It is certain that thousands of irrigations have 
been practised which only serve to keep up the irri- 
tation they were intended to allay. This is espe- 
cially the case with carbolic acid irrigation, of either 
one, two, or three per cent. The danger of poison- 
ing is very considerable; but, apart from that, the 
danger of irritating the inflamed tissue of the pleura 
is more uniformly present. Cases treated by carbolic 
acid irrigation have been described complacently as 
sustaining a treatment of three months, which, in a 
non-complicated case, itself impugns the treat- 
ment. In two of my own cases, one per cent, solu- 
tion of carbolic acid was used for irrigation when 
the temperature rose; but the child became restless, 
as from pain, and the temperature rose higher. Irri- 
gation with a solution of bichloride i : 6000 was 
substituted, and the temperature fell, not again to 
rise. 
Out of the five cases reported by Dr. Daniel only 
one Avas irrigated. The irrigation was made daily 
with a two per cent, solution of carbolic acid, for a 
period of nineteen days, yet the fever continued REMARKS UPON EMPYEMA. 
33 
with little abatement. It is evident that, apart from 
the irritation of the inflamed pleura, repeated irri- 
gations tend to thwart the two essential parts of the 
healing process. Each tends to break down the 
delicate adhesions forming between the pleura, and 
to oppose the reexpansion of the lung. No one can 
deny their utility when pus is found foetid at the 
time of the operation, or if it become so afterward, 
for it is important to remove fetid pus or gangrenous 
masses at once, and not trust to their gradual elimi- 
nation. But there is no proof that it is important 
to remove fluid and laudable pus at once, but only 
to provide for its free, steady, and uninterrupted 
gradual evacuation. As soon as the internal tension 
of the pleural cavity has been relieved by removal 
of such excess of fluid as spurts with force through 
the drainage-tube, and as soon as drainage is insti- 
tuted and maintained, tendencies to absorption of 
pus are arrested and the lung is enabled to reexpand. 
If the pleural cavity were empty of fluid, but, from 
imperfect collapse of its walls, filled with air at ordi- 
nary atmospheric pressure, expansion of the lung 
would be retarded as much as in the presence of 
fluid. This is sufficiently demonstrated by the acci- 
dent of pneumothorax. There is really no advan- 
tage in removing the pus faster than the lung can 
follow its retreat, and the contact of the pleural 
surfaces be effected. 
In my case, no irrigation was made at the time of 
the operation. The next day, the rectal tempera- 
ture, which had been 104° on the afternoon of the 
operation, had fallen to normal; the dressings were 34 
JACOBI, 
saturated, and were removed. During removal, air 
was twice, but only twice, sucked into the pleura. 
During the next week I did not see the child, but 
the dressings were changed every two days by another 
physician. The temperature, taken in the mouth, 
was reported as normal during the week, but the 
cough was severe, while it had been scarcely per- 
ceptible before. On the seventh day I saw the child 
again, and found the rectal temperature The 
percussion resonance over the lung was nearly nor- 
mal, the breath sounds harsh and bronchial without 
vesicular murmur; the heart was in place. In 
changing the dressing this time, the cotton wool 
outside the antiseptic gauze was replaced by oakum. 
Before replacing the dressing, air was again drawn 
into the chest with a loud noise. Again I did not 
see the child for four days, during which, however, 
the dressing was twice changed by the other physi- 
cian. On the eleventh day after the operation, I 
found the rectal temperature 103°, the child coughing 
much, still pale and languid, complaining much of 
pain in the chest. On this occasion, and for the 
first time, I irrigated from a fountain syringe with a 
warm solution of corrosive sublimate, containing 
1 : 6000. On this occasion, no air was drawn into 
the chest. Two other changes were also made in 
the treatment: a valve of rubber tissue, hitherto im- 
perfectly applied, was accurately adjusted over the 
fistula, and antipyrin was given in five-grain doses 
every three hours. Three effects were observed : The 
temperature fell permanently after seven doses of the 
antipyrin had been taken. The discharge lessened REMARKS UPON EMPYEMA. 
35 
so much that the dressing remained untouched for a 
week, and was then found scarcely soiled. The 
cough lessened, the child became lively and free 
from pain, and a week after the irrigation, eighteen 
days after the operation, was found running about, 
eating well, and appearing quite well. The dressing 
was replaced, left a week longer, when the fistula was 
found to be granulating abundantly, the discharge 
entirely trivial. It is possible that the tube might 
then have been removed ; it was evident that the 
pleural cavity had contracted to a sinus around the 
tube. For greater security, the tube was simply 
shortened, and only entirely removed a week later, 
on the thirty-second day after the operation. The 
fistula closed immediately. 
On the eleventh day, when irrigation was per- 
formed, the character of the discharge had changed— 
become slightly sanious, with a few small fibrinous 
coagula. But there was no evidence of their de- 
composition, nor of septic infection of the wound, 
although on several occasions the dressings had been 
too loosely applied, and the antisepsis imperfect. 
The fever, pain, and cough seemed to have been 
kept up by the continued inflammation of the 
pleura, and it is this which seemed to subside 
promptly under the combined influence of the bi- 
chloride irrigation, the valve, and the antipyrin. 
The use of a valve in the dressing of the em- 
pyemic fistula has received much less attention than 
it deserves. The elaborate valvular apparatus de- 36 
JACOBI , 
scribed by Phelps, in 1880,1 does not seem to have- 
been employed by any one else. It necessitates a 
double opening in the chest, and is otherwise too 
complicated for general use. When a valve of 
bandruche was used around the trocar, in the 
French method of operating which preceded the 
antiseptic, no arrangement was made for keeping up 
a valve action by the dressings. Dr. Cabot, in his 
paper of 1880, is the first writer I know of who has 
perceived the desirability of a valve. He recom- 
mends, however, to utilize the mackintosh of the 
Lister dressing for this purpose, allowing it to over- 
lap the gauze upon the skin, instead of, as is usual, 
falling short of the dimensions of the gauze. It 
seemed to me that this same idea could be more 
effectively carried out by placing a piece of rubber 
tissue, the size of my palm, directly over the open- 
ing, upon the skin and under the dressing. The 
piece of rubber was, of course, previously soaked in 
a bichloride solution. After the conclusion of my 
case, I found that Bouveret has advised a similar 
valve to be placed directly over the fistula, but this 
to be attached to the upper border by collodion, 
and left free below. My thin layer of rubber tissue, 
as soon as it was in situ, became closely applied to 
the skin bv atmospheric pressure. 
On the first dressing a valve had been imperfectly 
applied, and continued to be so until the eleventh 
day. Up to this time air was always drawn into 
the lung as soon as the dressing was removed. On 
1 New York Med. Record, 1880. REMARKS UPON EMPYEMA. 
37 
the eleventh day a better valve was made of thin 
rubber tissue, and a week later, when the discharge 
had almost entirely ceased, no air was drawn into 
the chest when the valve and dressings were re- 
moved. 
It might at first sight appear as if a piece of rub- 
ber, closely applied over the opening as above de- 
scribed, would interfere with the discharge of pus 
through the drain. The discharge is, however, 
effected during expiration, when the intra-pleural 
pressure becomes superior to- the pressure of the 
external air against the valve, and, therefore, raises 
it sufficiently for fluids to trickle out. 
Peyrot1 has shown that in pleural effusions the 
type of expiration changes; the force of inspiration 
diminishes as the expansion of the chest becomes 
incapable of determining a vacuum, and expiration 
becomes the principal act. It becomes active in- 
stead of passive, as is normal, and may be decom- 
posed into two periods. In the first the glottis 
remains closed, and air is pushed toward the depths 
of the bronchi. In the second period the glottis 
opens, and air is expelled with a sigh. This form 
of respiration is normal to birds. It also greatly 
resembles that of frogs, where the lungs are not 
contained in closed cavities, and where, therefore, 
there is no mechanism for aspiring air by the crea- 
tion of a potential vacuum. While the glottis is 
open air enters the upper air-passages. The glottis 
is then closed, and air is jerked toward the termini 
1 Archives Gen. de M6decine, 1876. 38 
JACOB], 
of the bronchi by movements resembling those of 
deglutition. 
This change of respiratory type is well shown on 
some respiratory tracings taken from the right side 
of a dog’s chest during successive injections of 
plaster-of-Paris into the left pleural cavity. The 
expiration begins to be prolonged and divided into 
two phases during the third injection, and from that 
moment the inspiration continues to diminish in 
amplitude and duration—the expiration to increase 
in both. 
In another dog, where a carotid tracing was taken 
during the injection, the trace immediately showed 
an increase in the respiratory oscillations, and a rise 
of blood-pressure to the extent of five millimetres of 
mercury. After the fifth injection there was a sec- 
ond rise of blood-pressure to the extent of ten milli- 
metres. When twelve ounces of plaster-of-Paris had 
been injected, the pulsations were arrested, and the 
manometer needle fell fifteen millimetres. 
The change of respiratory type in pleural effusions 
is not due to pressure exerted on the lungs, but to 
the inadequacy of the inspiratory expansion to effect 
its purpose of drawing air into the lung. This in- 
adequacy persists after evacuation of the fluid and 
establishment of a fistula, although the abnormal 
positive intra-pleural tension be then greatly dimin- 
ished. Therefore, the new type of breathing per- 
sists, though to a less degree. It would be very 
interesting to demonstrate this upon the human sub- 
ject, but I have not been able to do so. 
It is easy to see that the change of type is an ad- REMARKS UPON EMPYEMA. 
39 
vantage in the double task imposed—that of expel- 
ling fluids from the chest, which must be effected 
during expiration, and of reducing to a minimum 
the aspiration of air into the pleura, which would be 
effected during a vigorous inspiration. Correla- 
tively with these desiderata, which inverts the nor- 
mal ones, we find experimentally, and shall probably 
find clinically when we look for it, that the normal 
force of the respiratory movements is inverted — 
inspiration is diminished and expiration is in- 
creased. 
The immobilization of the chest walls on the af- 
fected side while an intra-pleural effusion exists, and 
their collapse—especially marked in children after 
the fluid is evacuated—seem to be the mechanism 
by which inspiration is diminished. The cough, 
which, as in our case, comes on or is aggravated 
after the operation, is one of the means by which 
expulsive expirations are increased. 
With these favoring circumstances, even the or- 
dinary Lister dressing often suffices to solve the 
problem of so greatly diminishing the entrance of air 
through the fistula, that the air remaining within 
the pleura may become rarefied, the lung sub- 
mitted to unopposed atmospheric pressure, and, 
therefore, reexpanded. This is the true mechanism 
of the clinical phenomenon which Dr. O’Dwyer has 
recently discussed with a certain despair of finding 
the explanation. Although air be not absolutely 
excluded from the pleura, yet if it be not renewed, 
or renewed in less proportion than it is absorbed, 
it will soon become rarefied, and the conditions of 40 
JACOBI, 
pulmonary reexpansion are then established as posi- 
tively, though less vigorously, than when a complete 
vacuum exists. 
Homolle1 has contrived to measure intra-pleural 
tensions by means of a manometer attached by a 
lateral stop-cock to the trocar used in evacuating 
effusions. In a case of empyema the measurements 
varied thus: 
Before any fluid was withdrawn the intra-pleural 
pressure was positive, and equivalent to ten milli- 
metres of mercury. When 500 grammes had been 
withdrawn, it had sunk to 0.002 millimetre; when 
900 grammes, the pressure became negative to the 
extent of 0.007 millimetre, and after withdrawing 
1000 grammes, the negaive pressure was eighteen 
millimetres. 
In the dog in whose pleura I injected water 
through an air-tight canula communicating with a 
manometer, the pressure was negative to the amount 
of five millimetres, and remained so after 300 
grammes of water had been injected. 
These facts show that the pleural cavity may con- 
tain some air and some fluid, and yet remain in a state 
of negative pressure relative to the atmospheric air, 
which, therefore, should not be opposed in expand- 
ing the lung. 
As Weissberger has further pointed out, during 
the process of adhesion and obliteration of the 
pleural cavity the lung becomes tugged forward 
piece by piece, and when the adhesions are com- 
1 Revue Universelle MSdecine et Chirurgie, 1879. REMARKS UPON EMPYEMA. 
41 
plete, the lung must be drawn out by every expan- 
sion of the thorax. 
The presence of fluid in the chest when there is a 
free opening for it to run out, offers little more 
obstacle to the reexpansion of the lung than does the 
pressure of fluid in the flask to the reexpansion of 
the balloon. This is because the pressure of the 
flu:d is always superior to that of the external air, 
and therefore easily overcomes it. 
It is the clinical observation of frequent and even 
speedy recovery with the use of the Lister dressing 
alone,1 which demonstrated that the above processes 
must take place as described. 
But whatever beneficial influence, from the dyn- 
amic point of viewq may be exercised by the Lister 
dressing, is certainly greatly intensified by the use 
of such a valve as I have described. I think there 
is no doubt that the cavity became contracted to a 
sinus on the fifteenth day after the operation, and 
that the tube might have been removed at least ten 
days earlier than it was. 
To the extent to which the occlusion of the fistula 
during inspirations is complete, the normal type of 
respiration tends to be reproduced, and the cavity 
to be obliterated by more vigorous inspiration of 
the lung. 
Peyrot remarks that when, being bound by false 
membranes, the lung is unable to expand, the 
1 In one case reported by Bouveret, the empyema was com- 
pletely cured in nine days, the shortest time on record. The 
expansion of the lung was so rapid that it certainly preceded the 
cicatrization of the pleura. 42 
JACOBI, 
diminution of pressure in the pleura seems to favor 
putrefaction or fermentation, even without contact 
with external air. The importance of the pulmo- 
nary expansion as a means of obliterating the 
cavity is so great, and as such has always been so 
Cast I. 
In profile. 
well recognized, that the frequent failures of such 
methods as subaqueous drainage1 seem more sur- 
prising than its successes. These failures are the 
1 Playfair: Transactions London Obstetrical Society, 1872. REMARKS UPON EMPYEMA. 
43 
best possible proof that the antiseptic part of the 
problem is as important as the mechanical; that 
sepsis is liable to occur through infection of the ex- 
ternal wound, even when air is rigorously excluded 
from the pleura; and finally, that constant irrigation 
of granulation tissue that should be left in the great- 
est repose, interferes both with the healing and with 
the mechanical mechanisms of reexpansion. Dur- 
ing the treatment of the boy Frank, I took a certain 
number of casts of his chest, by a process which is 
very simple, but which I have not hitherto seen 
described. I encircled the thorax with a cyto- 
meter, and having carefully removed the instrument 
I placed it, closed, on a perfectly flat surface, and 
Cast II. 
poured in fluid plaster-of-Paris. A cast was thus 
obtained, one-half an inch in thickness, and which 
accurately represented a transverse segment of the 
chest, and the inequalities of the two sides. The 
first cast was taken on the eighteenth day, a week 44 
JACOBI, 
after the irrigation. It represents a segment imme- 
diately under the axillae. The second cast is from 
Cast III. 
Cast IV. 
the same locality, and is taken a week later, the 
twenty-fifth day. The two other casts were taken REMARKS UPON EMPYEMA. 
45 
a few days after cicatrization. No. III. from the 
level of the axillae, No. IV. from the level of the 
seventh rib. The odd-looking projections on the 
posterior aspects of these casts are due to a mistake 
made in the application of the cytometer, which 
was put on inside out. This does not, however, 
essentially change the character of the casts. 
The general shape of the affected side in the 
fourth cast well illustrates Peyrot’s remark, that 
there is a total deformity of the chest, which results 
in a sort of “oblique oval thorax.” I regret very 
much not to have secured a cast on the preceding 
week, as then the affected side was much more col- 
Casts superimposed. 
lapsed, the shoulder drawn over and downward, so 
that the alarmed parents inquired about the danger 
of permanent deformity. The cast of the eigh- 
teenth day shows : First, a deviation of the sternum 46 
JACOBI, 
toward the affected side, and half an inch to the 
left of an antero-posterior line traversing the seg- 
ment from the vertebral column. Second, a marked 
diminution in circumference, in transverse and in 
antero-posterior diameters as compared with the 
sound side.1 The cast taken the following week, 
however, shows that the differentiation on the first 
occasion had depended upon an enlargement of the 
right half of the chest, as well as on the contrac- 
tion of the left. The deviation of the sternum was 
much less ; and the right circumference both to the 
deviation and to the median line was two inches 
less than it had been before the transverse diameter 
was diminished an inch; the antero-posterior the 
least of all—a quarter of an inch.2 The measure- 
1 Measurements, October 14th ; 
Circumference, left (affected side), to point 
of deviation 
Inches. 
of sternum ..... 
714 
Circumference, right, to point of deviation of sternum . 
ioJ4 
Circumference to median line, left . 
8* 
Circumference to median line, right 
IO 
Transverse diameter to median line, left 
Transverse diameter to median line, right 
4K 
Antero-posterior diameter, left 
3 
Antero-posterior diameter, right 
4 
2 Measurements, October 22d : 
Circumference to deviation, left 
9x/i 
Circumference to deviation, right . 
814 
Circumference to median line, left . 
9A 
Circumference to median line, right 
8 
Transverse diameter, left 
4% 
Transverse diameter, right 
3lA 
Antero posterior diameter, left 
3'A 
Antero-posterior diameter, right 
3X ments of the left side are increased, not only over 
those of the previous week, but over those of the right 
side, except the antero-posterior diameter, which is 
still one-quarter inch smaller. As before, the trans- 
verse diameter exceeds the antero-posterior. 
In the following week, after cicatrization of the 
fistula, the sternum has returned to the median line, 
the diameters of the two sides of the chest are nearly 
the same, but the right circumference exceeds the 
left by one and a half inches. Below, at the level 
of the xiphoid cartilage, the circumferences are 
equal; to the median line, both diameters larger on 
the right side by one-quarter inch.1 
It is interesting to be able to measure thus graphi- 
cally the compensatory hypertrophy and shifting of 
the sternum and mediastinum during the collapse of 
the left lung, and the gradual diminution of this 
REMARKS UPON EMPYEMA. 
47 
Inches. 
1 Measurements, November 2d, under axillae : 
Circumference, left ........ 
8J4 
Circumference, right ....... 
9^ 
Transverse diameter, left ...... 
3^ 
Transverse diameter, right ...... 
3^ 
Antero-posterior diameter, left ..... 
4 
Antero-posterior diameter, right ..... 
4 XA 
At level of seventh rib and xiphoid cartilage—cartilage 
deviated to right: 
Circumference to median line, left ..... 
8* 
Circumference to median line, right .... 
9% 
Circumference to deviation, left ..... 
854 
Circumference to deviation, right . . . . 
854 
Transverse diameter, left ...... 
3^ 
Transverse diameter, right ...... 
3X 
Antero-posterior diameter, left ..... 
4% 
Antero-posterior diameter, right ..... 
41/* 48 
REMARKS UPON EMPYEMA. 
hypertrophy and restoration of normal proportions 
as the collapsed lung expanded. 
In concluding this paper, which has not aimed at 
being systematic, but which has taken up details of 
interest as they occurred to me, there is one further 
remark to make. It seems to me that the two com- 
mon observations of the frequency of empyema in 
children, and of its usually favorable course, are 
observations mutually correlative. The favorable 
prognosis does not apply to the empyemas of infec- 
tious diseases; nor is it solely due to the greater 
elasticity of the chest walls in childhood, permit- 
ting more facile collapse. But the appearance of 
pus in the effusion is to be considered less signifi- 
cant, because more easily excited by the same 
degree of inflammation. It would seem as if the 
rich system of subendothelial- lymphatics in the 
pleura,1 poured out leucocytes freely through the 
intercellular stomata, when these are dilated in the 
inflammatory hyperaemia of the pleura, and during 
the preliminary shrinkage of the endothelial cells.2 
Pus, therefore, appears in the effusion before the 
pleura has became thoroughly infiltrated, and con- 
tinues to be secreted so long as the stasis remains in 
the vascular and lymphatic capillaries. 
1 Klein: Anatomy of the Lymphatic System. 
2 Delafield : Studies in Pathological Anatomy. AKLN Al iKR I50 Cl BIC CENTIMETRES OF WATER HAD BEEN INJECTED INTO LEFT PLEURA. 
A. Respiratory trace still further amplified. 
B. Tracing by a needle of a manometer which was connected with left pleural cavity by means of 
the T tube through which the injections had been made. Needle falls during inspiration, rises with 
expiration ; mercury rose five millimeters in proximal limb of manometer showing persistence of nega- 
tive pressure in pleura in spite of injection. 
4th injection, 75 c. c. plaster of 
Paris. 
7th injection 
Shows Change in Respiratory Type during Successive Injections of Plaster of Paris into Left Pleura. Tambour placed 
on Right Side of Thorax 
In these traces, ascending lines mark inspiration, descending linesmark expiration. Inspiration takes place in two times, marked by a vertical ascending line, 
followed by an oblique ascending line. The expiratory trace is also composed of an abrupt descending line followed bv an oblique descent. The peculiarities are 
most marked in trace D. 
6th injection. 
5th injection. 
TRACE II. 
E. Convulsive gasps after arrest of respiration. 
TRACE III. 
A. Normal respiratory trace. Eleven respiratory movements in unit of time. 
B. Respiratory tracing from right side of chest, taken immediately after plunging one arm of glass T tube into left pleural cavity. The inspiration is amplified, slightly accelerated 
twelve respirations in unit of time. 
Traces taken with a Marey Tambour on Right Side of Chest. The Glass Tube Plunged into Left Pleura. 
1st injection. Rise of 
blood pressure 5 
millimetres. 
5 th injec- 
tion. Rise 
of blood 
pressure 10 
millimetres. 
Fall of manometer needle 15 millimetres from 
level («) to (b) after arrest of pulsations. 
Carotid tracing 
normal. 
Pressure=20 
millimetres. 
TRACE I. 
TRACE IV. 
Abscissa, 
Normal Tracing. 
Continua- 
tion of 
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