Reprint from Medical and Surgical Reporter. 
A CONTRIBUTION 
TO THE 
OPERATIVE TREATMENT 
w 
OF 
Purulent Pleural Effusions. A CONTRIBUTION TO THE OPERATIVE TREATMENT 
OF PURULENT PLEURAL EFFUSIONS.* 
BY EDWARD T. BRUEN, 
Physician to Philadelphia Hospital, and Assistant Physician to University 
Hospital, etc., 
AND 
J. WM. WHITE, 
Surgeon to Philadelphia Hospital, AssistaiiTSurgeon to University Hospital, etc. 
The following paper is based upon thirteen cases of empyema treated 
since 1877 in the Philadelphia Hospital, and in that of the University of 
Pennsylvania. They are selected from a number, because their history 
has been followed closely throughout. In two of these cases resection 
of the ribs was practiced ; one of them will be subsequently detailed, and 
the portions of ribs removed will be exhibited. A third case, an adult 
Italian with an empyema of three weeks' standing, was treated by aspi- 
ration, with subsequent introduction of a drainage-tube, which was re- 
moved within three weeks with a result of perfect recovery. A fourth 
case, also an Italian, with purulent effusion dating six weeks prior to 
operation, was treated with a single aspiration, with a result of cure. 
The history of the fifth and sixth patients will be subsequently de- 
scribed ; of the remainder three are still under observation. In these 
last three drainage-tubes have been inserted, and the cases have been 
steadily improving; one of them will be presented this morning. Four 
other cases have been entirely convalescent for three years, but still re- 
tain an open sinus, from which there is a slight discharge. 
CAUSES OF EMPYEMA. 
The pleura possesses the power of very rapidly secreting pure pus ; 
our clinical records showing instances in which purulent collections have 
accumulated in thirty-six hours. In some of these cases the general 
health had been depreciated by intercurrent disease other than pleural. 
In one instance in the University Hospital, aneurism was associated with 
old pleural adhesions ; in another phthisis was the antecedent. 
In children the rapid formation of pus is proverbial, and in pleuro- 
*Read before the Medical Society of the State of Pennsylvania, at its meeting in 
Philadelphia, 1884. 2 
pneumonia the effusion is often semi-purulent. Acute pleurisy can 
terminate in cure, or in sub-acute or chronic inflammation, with effusion, 
or in the same with adhesions, or empyema. 
It is important to determine the proportion of purulent formations 
which result from undisturbed pleural effusions. 
Trousseau and writers of his day advocated paracentesis, dreading pur- 
ulent transformation if treatment was delayed. 
Albutt* writing in 1872, shared this view;. 
The chief predisposing condition towards the purulent transformation 
of undisturbed pleural effusions is lowered vitality, scrofulous constitu- 
tion, and intercurrent disease. 
The operation of paracentesis in serous effusions is often not practiced' 
for fear it may favor purulent transformation. This result need not be 
feared, if care is exercised to prevent the admission of air or organisms 
within the chest, and if at the same time clean antiseptic instruments 
are used. The accidental admission of air under the above circumstances 
is not necessarily serious. The predisposing causes of empyema conse- 
quent upon paracentesis are similar to those which favor purulent trans- 
formation in undisturbed pleural effusions. Sero-fibrinous pleural effu- 
sion complicating phthisis is not frequent, for the pleurisy of this disease 
commonly consists in the effusion of dry lymph. If sero-fibrinous effu- 
sion does occur, it is readily convertible into pus. The operation of par- 
acentesis does not increase the tendency to purulent transformation, and 
is positively indicated, since there is but little disposition for these effu- 
sions to be reabsorbed. 
In phthisis, pleurisy occurs whenever hydro-pneumothorax is produced 
by rupture of the visceral pleura, and the effusion usually soon becomes 
purulent. 
Collections of pus in the chest-wall may follow wounds of the pleura 
or fractures of the ribs, and peri-hepatic inflammations ; or abscesses of 
the liver may perforate the pleura and produce empyema. 
TERMINATIONS. 
Empyema may last months, or years, terminating in evacuation of the 
pus externally through an intercostal space, or it may be evacuated 
through a bronchus. More rarely an empyema is evacuated through the 
diaphragm into the peritoneum or colon, or into the mediastinum, thence 
along the vertebral column as far as the psoas muscle ; or through the 
tissues forming the abdominal wall, and so outward. 
The termination of spontaneous external evacuation through an inter- 
costal space may follow a periostitis with subsequent caries or necrosis 
of one or more of the ribs, and it is preceded by oedema of the intercostal 
tissues. 
* Practitioner, vol. 2, '72, p. 77. 3 
EFFECTS OF A PLEURAL EFFUSION UPON THE LUNG. 
1. The lung may be compressed until the air is absolutely expelled and 
the lung itself is flattened into a small space against the vertebral col- 
umn, occupying an area mostly in the scapular region, sometimes not 
larger than the palm of the hand. 
2. The fluid may force the lung upward, so that we may outline it an- 
teriorly, perhaps as low as the second rib, occupying a variable area of 
the scapular region. 
3. The lung may be bound down to any portion of the chest wall, or 
flattened upon the diaphragm. The substance of the lung may be hep- 
atized, or the compression may result in complete atrophy of the lung. 
DIAGNOSIS OF EMPYEMA. 
The diagnosis of empyema presents the usual group of physical signs 
indicative of non-purulent pleural collections. The crucial test is by 
puncture ; for large collections of pus may persist in the chest with an 
abnormal temperature, yet without the range characteristic of purulent 
retention. The cases on which these observations have been made were 
usually those of chronic pulmonary and pleural disease, in which the 
pleurae were thickened and indurated. The diagnostic puncture can be 
effected by a hypodermic syringe attached to a needle rather larger than 
the one in ordinary use. 
INDICATIONS FOR TREATMENT. 
In the scrofulous, or those predisposed to phthisis, it is difficult to say 
how long the lung may be compressed, and yet, after recovery, dilate so 
as to fill the chest when the pressure is removed. The healing process 
in a pleural cavity after effusion, whether serous or purulent, occurs 
through the medium of adhesions of the inflamed pleural surfaces. 
Every movement of the chest parieties, then, drags the surface of the 
lung with it. During the persistence of the fluid the degree of motion is 
small, for the ribs, pressed out by an excessive quantity of fluid, are pre- 
vented from rising or falling, whilst the distension of tile chest diminishes 
the elasticity and favors paralysis of the intercostal muscles. When the 
fluid is evacuated or absorbed, the character of the respiratory move- 
ments is improved, and they diminish in frequency as well as in shal- 
lowness; The lung being now adherent, is dragged by the ribs in all 
their increasing movements, and as the lung expands the adhesion to 
the chest wall increases. Each fresh expansion of the lung results in 
further adhesion to the costal surface, which then acquires more power 
over the lung to promote its return to the normal state. 
Some authors* contend that air admitted into the pleural sac is opposed 
to the healing process of an empyema. In reply to this it may be said 
* Cabot, Boston Med. and Surg. Jour., August 16,1883. 4 
that the forces of expansion of the chest, are the column of air inspired, 
the elasticity of the thoracic parieties, and the action of the respiratory 
muscles, assisted by the natural tendency of the visceral pleural surface 
to adhere to the costal pleural surface by an action similar to that seen 
in a boy's sucker. The opposing forces are the elasticity of the lungs, 
and possibly the small amount of air contained within the pleural cavity. 
These latter forces are manifestly inconsiderable, when compared with 
the forces inflating the lung, and the granulating pleural surfaces will 
naturally tend more readily to adhere than the physiologically smooth 
pleural surfaces. With this allusion to the method by which an empy- 
ema is healed, and in view of the danger of prolonged compression of the 
lung under these circumstances, added to the plain general principles of 
surgical experience in the treatment of purulent matter in the pleural 
sac, we submit the following indications for treatment : 
Purulent effusion should be evacuated by careful aspiration as soon as 
recognized. The tubing and needles should be first immersed a few min- 
utes in carbolized boiling water. The subsequent treatment in children 
and adults differs. In the former a cure may be accomplished by one or 
two aspirations. An almost indefinite list of cases outside of our own 
experience could be submitted to attest this point.* In children, when 
aspiration fails a free incision into the chest is often sufficient.! 
Drainage-tubes can sometimes be disregarded in very young children, 
because their chest-walls are so elastic that collapse of the cavity and its 
obliteration by adhesions is perfectly practicable. As the age of children 
increases, the state of their chest-walls approximates that of the adult, 
and after the age of ten years the treatment is usually identical. This 
treatment should be a preliminary trial of aspiration, but absorption 
failing to occur, a prompt recourse must be had to drainage by the intro- 
duction of a tube into the chest through an intercostal space, in a man- 
ner to be hereinafter described. This tube should be sufficiently large 
to secure constant free drainage and thus prevent the stagnation of the 
pus and its decomposition. If thorough drainage is accomplished, the 
use of disinfectants by intra-thoracic injections is rendered unnecessary, 
unless a stimulant to the granulating surface is required. In this latter 
case the usual surgical principles should govern the character of the solu- 
tion and its strength, the writers' preference being given to Lugol's 
solution. 
When purulent pleural effusions occur in the course of phthisis, or in 
* 1. Dr. J. Hunt, Med. T. and Gaz., Feb. 15, '79. Child 14 mos. Two aspirations. 
Cure. 2. N. Y. Med. Rec., 1879. Child 2 yeaA of age. Two aspirations. Cure, with 
thickening of pleura. 
tSee case of Dr. G. Post, Beiruth, Syria, girl 8 years. Two aspirations; incision. 
Cure 2 mos. J. Healey and E. P. Hind, N. Y. Med. Rec., 1879. Child 3 years. Two aspi- 
rations between seventh and eighth ribs near angle. Incision between ninth and 
tenth rib. No drainage-tube. Recovery in a month. 5 
this disease when complicated with pneumothorax, the propriety of op- 
erative treatment has been already indicated. 
Resection of the ribs should be practiced upon indications drawn from 
anatomical considerations. 
If the opening through the intercostal space fails to provide sufficient 
drainage, or if the discharge continues three or four mouths with a dele- 
terious effect upon the general health, and a physical examination shows 
that the pleural cavity, although diminished in size, is still so large that 
it is improbable that obliteration of the cavity can occur, resection of one 
or more ribs should be practiced. 'This operation offers freer access to the 
cavity of the pleura, and also allows the chest wall to collapse to such an 
extent as to produce obliteration of the cavity by permitting its walls to 
approximate one another.* 
Finally, with reference to the withdrawal of the drainage-tube. This 
should be done as soon as a physical examination shows that the lung 
has descended sufficiently to allow approximation of the surfaces of«fhe 
abscess. When this has occurred, the presence of a drainage-tube in a 
sinus becomes a source of irritation. The sinus can be packed with lint, 
and treated on general principles. 
POSITION OF OPENING. 
Having decided in any case that no disposition exists to spontaneous 
closing of the cavity after the performance of paracentesis alone, and that 
it is necessary to supplement this operation by one looking to the thor- 
ough, complete, and continuous drainage of the suppurating region, the 
question which presents itself is how best to secure this drainage. 
This, it seems to us, after a careful review of the matter from both a 
clinical and an anatomical standpoint, is not a difficult one to answer. 
The general principle which applies to the treatment of extra-thoracic 
abscesses applies here. To do away with the possibility of accumulation 
of pus, to obviate the necessity for frequent and often mischievous inter- 
ference with the granulating inner surface of such cavities by injection 
or irrigation, the most dependent point consistent with safety to neigh- 
boring tissues or organs is always selected for the puncture, f 
This point is to be found on the right side in the seventh intercostal 
space, and in a line with the posterior border of the axilla. On the left 
*Seq Dandridge's cases, Exsection of Ribs in Treatment of Empyema, Ohio Med. 
Jour., 1881-2, p. 57. 
Homen's rev. of Estlander's, Management of Empyema by Resec. of Ribs. Arch, 
fur Klin. Chir., Berl., 1881; also Korting, on Puncture, Incision, Resection and Anti- 
septic Injection. 
f It has been stated (Porritt, op. cit., p. 144) that " the only point of resemblance be- 
tween an empyema and an abscess is the pus which each contains." But for our pur- 
poses the above establishes the parallel quite sufficiently, even admitting it to be true, 
which we are not inclined to do. 6 
side it should be one space lower, and in the same line. More posteriorly 
the ribs find intercostal spaces are covered by large masses of muscle, the 
intervals between the ribs are greatly diminished ; the intercostal arteries 
running more horizontally than the ribs themselves, cross the spaces di- 
agonally, and are thus exposed to injury. More anteriorly the higher 
level of the diaphragm not only exposes it to injury during the operation, 
but by exercising pressure on the drainage tube interferes with its satis- 
factory action ; and then, too, the opening is not by any means in the 
most dependent position in the usual posture of a patient after this 
operation. 
The eighth intercostal space on the left side, and the seventh on the 
right, may be most easily found by tracing outward the seventh rib, 
which is the lowest attached directly to the sternum, and which forms 
the upper boundary of one of these spaces and the lower boundary of the 
other. Or the rule given by Mr. Porritt may be adopted, viz : Mark on 
tli^skin the position of the angle of the scgpula, when the arm is by the 
side and also when the arm is raised above the head ; one inch below the 
middle of the line drawn between these two points will be found the de- 
sired spot. It should be said, however, that, though this leads accu- 
rately to the eighth interspace, the "spot" described by him is in our 
judgment somewhat too far posterior, and, at least from the operative 
point of view, is open to the objection above stated. 
The claim which has been advanced that because a certain number of 
cases of empyema have been opened in the fifth interspace anteriorly, 
that point should be selected for the performance of the operation, seems 
to us altogether without rational foundation ; first, because only a small 
minority of the cases of empyema open spontaneously, and not by any 
means all of them at that interspace ; and next, because the general 
principle which regards the workings of "nature" in such cases as a 
guide to the surgeon is a misleading and unsound one, which, if adopted 
jn other cases, would often lead to serious or fatal mistakes. 
INSERTION OF DRAINAGE-TUBE. 
Having selected the spot for the operation, its performance is extremely 
simple and devoid of danger. With an ordinary bistoury an incision 
should be made opposite the upper border of the rib, bounding the lower 
limit of the interspace, an inch to one and a half inches in length, and 
extending at first through the skin and superficial fascia; the deeper 
fascia and the intercostal muscles should then be divided on a director; 
the pleural wall, usually found thickened and unnaturally dense and re- 
sisting, picked up with the forceps, nicked and divided to an extent 
equal to the external incision, and the drainage-tube inserted. The 
division of the pleura will usually be followed by some hemorrhage, often 
quite free for a few moments; but it is almost never dangerous, comes 
chiefly from the granulations on the inner surface of the membrane, anq 7 
subsides spontaneously. The outer end of tile tube should be cut off 
parallel to and on a level with the surface of the chest-wall, and should 
be threaded with a silver wire or with a long thread of waxed hemp or 
silk, so that it may be easily recovered if it should pass into the pleural 
cavity. A long projecting end of drainage-tube is objectionable, because 
it is liable to become compressed by the dressing or by the clothing, so as 
almost or quite to occlude it. The same objection applies to the plan of 
hooking a drainage-tube around a rib and tying the ends together, one 
which adds slightly to the severity of the operation, necessitating 
another wound, and at the same time leaves the tube in a position much 
exposed to pressure and occlusion. 
The operation should be conducted with attention to antiseptic details; 
and we would recommend as an excellent dressing in which to receive the 
discharge, a thick layer of salicylated or borated cotton, over which may 
be placed some layers of carbolized gauze and macintosh. 
If the pus escaping from an empyema cavity which has been treated 
in this manner remains sweet and odorless, if there is no evidence of ac- 
cumulation, and, most particularly, if the cavity seems to be diminishing 
in size, no further local or operative treatment is either necessary or jus- 
tifiable. Attention should be paid merely to the general hygiene and 
nutrition of the patient, and to the perviousness and efficiency of the 
drainage-tube. 
If, however, in spite of these precautions, the pus is found to become 
fetid oi' ammoniacal, it will be proper, recognizing that this condition, in 
the vast majority of cases, results from imperfect discharge, and that no 
use of a septic or disinfectant lotion or injection can possibly remove it, 
to make a second and still lower opening through the chest wall, and 
carry a drainage-tube directly through from one to the other, allowing 
its curve or belly to rest upon the floor of the cavity. This may readily 
be done by gently passing a long, blunt-pointed probe from the original 
opening across the base of the chest, carefully avoiding the diaphragm, 
of course, and the lung, if it is at the base of the chest (a somewhat un- 
usual occurrence), and making the end of the probe prominent on the 
opposite side, in the lowest available intercostal space; then cutting 
down upon it just as in making the first opening, it may be drawn 
through, bringing with it the drainage-tube, which should now be 
secured at both ends. 
This will usually be followed by a marked change in the character of 
the discharge and in the condition of the patient; not infrequently by a 
rapid diminution in the quantity of the pus and in the size of the cavity, 
which may finally become obliterated, even although, with the imperfect 
drainage afforded by the opening, it has remained stationary for a long 
period. 
We have had two cases which illustrate this statement, but which it is 
not necessary to detail, as they are the ordinary cases of empyema, with 8 
the usual symptoms, and'the operations were performed after the manner 
just described. 
RESECTION OF RIBS. 
In a certain proportion of cases, however, this treatment proves una- 
vailing. 
Two or three months elapse, the cavity remains as large as ever, and 
the patient is losing in general health and strength. It then'becomes 
advisable to adopt some means to lessen the size of the cavity, and with 
it the extent of suppurating surface, and at the same time time to favor 
the formation of those adhesions which, as has already been observed 
are so useful, if not essential, indrawing the lung down and aiding in its 
expansion and the obliteration of the cavity. 
In such a case, the operation of exsection of a portion of the ribs on 
the affected side becomes justifiable. By permitting of the partial collapse 
of the chest wall on that side, it approximates the walls of the cavity, 
reduces its size, aids in the formation of adhesions, lessens the amount 
of pus secreted, and, as it may be performed with little or no danger to 
the patient, is evidently strongly indicated on theoretical grounds alone. 
And the results of the recorded operations which have been performed 
in suitable cases, amply justify the a priori view. 
The rules for the operation may be formulated as follows: 
1. The portions of the ribs selected should be those between their 
angles and their sternal attachments. Posterior to this, they are less 
movable, and are so close together that the difficulties of the operation are 
greatly increased. 
2. Those ribs between the third and tenth should be selected which 
most accurately, overlie the cavity. 
3. The number of ribs operated upon should be proportionate to the 
extent of the cavity. 
4. The length of the pieces excised should be proportionate to the 
depth of the cavity.* 
5. The operation should be done aseptically and subperiosteally, and 
when so performed is almost without danger ; and even in cases where 
large portions of ribs are removed, is followed by no permanent loss of 
function in the external respiratory muscles of that side. 
In the case of a patient from the medical wards of Blockley Hospital, 
suffering from a large empyema, involving the whole pleural cavity of 
the left side, we performed this operation in the presence of several of 
our colleagues, of Dr. D. Hayes Agnew, and of the medical class. 
It haviug been decided to remove portions of the fifth, sixth, and 
seventh ribs on the left side, a curved incision, ten inches in length, was 
carried through the overlying tissues, beginning about an inch above and 
*See paper by Dr. A. Homen. Langenbeek's Archiv fur Klin. Chir., Band xxvi., 
Heft. 1, p. 151. 9 
within the nipple, and terminating on the axillary line at about the 
ninth interspace. A large horse-shoe flap, consisting of skin, subcu- 
taneous tissue, and pectoral muscle, was reflected upwards, and the ribs 
exposed. A few small vessels were tied, and then the periosteum was 
detached from the ribs with an ordinary elevator'; an eyed probe, with an 
abrupt curve and carrying a chain-saw attached, was passed around<each 
rib separately at two places, and the requisite portion removed. By ex- 
ercising great care in denuding the under surfaces of the ribs, employing 
for that purpose a gouge curved on the flat, the intercostal arteries were 
pushed inward with the periosteum, and it was not necessary to tie a 
single one of those vessels. 
Two inches were removed from the fifth rib, two and a half from the 
sixth rib, and three from the seventh rib. 
A large drainage-tube was inserted into the cavity, the external wound 
brought together by wire sutures, and an aseptic dressing and compress 
applied. There were absolutely no unfavorable symptoms after the ope- 
ration. The greatly-improved drainage (which is one of the conspicuous 
benefits resulting from this operation, and is almost of itself a sufficient 
indication for its performance), caused an immediate improvement in the 
character of the discharge. The external wound united by first inten- 
tion. The general health and strength of the patient improved greatly, 
and the cavity notably diminished in size. 
The patient died two and a half years later of an acute bowel trouble, 
having outlived the average period of such cases at Blockley, and being 
then apparently on the road to complete recovery. 
This case and the method of operation may be taken as typical, and 
the result is even less favorable than may be anticipated in the large 
majority of cases. 
CONCLUSIONS. 
Our conclusions, then, may be formulated as follows: 
1. Those cases of pleural effusion which are most likely to become pur 
ulent, and therefore to need operative treatment, are those occurring in 
persons of lowered vitality, scrofulous diathesis, or who suffer from in- 
tercurrent disease. 
2. The diagnosis of empyema can only be made with absolute certainty 
by puncture and inspection of the fluid. This method of examination 
need not be delayed for fear of favoring the purulent transformation of a 
serous fluid, if proper aseptic precautions are observed. 
Dambrowski. Management of Empyema by Resection and Antiseptic Injection. St. 
Petersburg. Wochenschr., 1881. Williams, Treph. Ribs, N. 0. M. and S. Jour., 1874, 
p. 830. 
I. F. Wert, Birmingham, M. Rev., 1881, 2 vol., 47-58; also Tatham, on Resection of 
Ribs, B. M. J., London, '81. 
A Plea against Jlesection of Ribs, Leall, N. Y. Med. R., 1880. 
Fenger, Thoraeoplastic Operation, Resection Ribs, etc., Med. News, Philadelphia, 1882, 
p. 337. Roser. Oper. des Empyem., Berl. Klin. Wochenschrift, 1878, No. 46. 10 
3. In young children, one or two aspirations will often suffice for a 
cure. If these fail, simple incision of the chest without the introduction 
of a drainage-tube is often all that is requisite. 
4. In older children, and in adults, it is proper to aspirate once; but 
recovery not resulting promptly, a large drainage-tube should be inserted 
at the most dependent point. 
5. If, after this, drainage is still imperfect, as shown by the fetid char- 
acter of the discharge, a second opening should be made, and a tube car- 
ried directly across the base of the cavity. 
6. If after a suitable delay (from two to four months) there is no dis- 
position to permanent closure of the suppurating cavity, but if the lung 
has expanded sufficiently to indicate that it is capable of further descent, 
it would then be proper to facilitate its expansion and the obliteration of 
the cavity by removing certain portions of the ribs of the affected side. 
7. If thorough drainage is accomplished, the use of disinfectants by 
intra-thoracic injections is rendered unnecessary, unless a stimulant to 
the granulating surface is required. 
8. In cases in which the lung is at the bottom of the chest and bound 
fast to the diaphragm, or in which it has been so atrophied prior to aspi- 
ration that there is no possibility of reinflation, or in which it is occupied 
by a tuberculous or an inflammatory infiltration, this operation is contra- 
indicated.