EMPYEMA.

BY WILLIAM F. WESSELHOEFT, M.D., Boston, Mass.

The subject of empyema suggested by your chairman is one of great importance. As in other surgical conditions, the earlier it is recognized, and the earlier the operative measures are instituted the more favorable is the outlook. If overlooked, the future of the patient is one of long suffering and death.

While accuracy in diagnosis, due to better training and greater care, is everywhere on the increase generally, we do not infrequently see cases of empyema which have been disregarded, or have been recognized only after long delay. This is sometimes because of the insidious onset of the disease, and sometimes because an empyema has developed from a pneumonia and the continued illness has been thought due to the lung condition not clearing up. A mistake will rarely be made if one is on the lookout for this condition and has its diagnostic points clearly in mind.

Excluding infection of the pleura through a wound, empyema may occur primarily from a pyogenic infection, probably through the blood current. It may occur secondarily from an infection reaching the pleura from a neighboring focus, as a pneumonia or abscess of the lungs; from a suppuration beneath the diaphragm, disease of the mediastinum, or an infection of the chest wall itself. Most cases are believed to begin with an exudate of serum, which later becomes purulent from an increase in leucocytes.

In all cases the pleura is thickened and is usually covered with fibrinous exudate.

While usually the pus is free, it may be limited by adhesions between the lung and wall to a certain locality. Such localized collections are most frequent between the diaphragm and base of the lung, due to infection carried from the abdomen through the lymphatics, and between the lobes of the lung secondary to the pneumonia. The amount in a given case may vary from very little to the full capacity of the cavity, in which latter case the lung is compressed and the other thoracic organs displaced so that the apex beat of the heart may be found several inches from its normal position.

The symptoms are those of pleurisy at first and septic toxæmia and as the fluid increases the respiration becomes mildly or profoundly embarrassed. The fever is usually irregular, with considerable variation between the morning and evening readings, and leucocytosis is present.

If unrelieved, death ensues from exhaustion or sepsis. Rarely does the pus rupture into a bronchus or burrow its way out through the thoracic wall and give relief. As operation is imperative, the diagnosis of this condition becomes of the utmost importance, and this is based on the following points:

Inspection. At first, when there is little fluid, the two sides show little difference. As the fluid increases, however, the affected

side shows less respiratory movement, and with a large amount of fluid present there may be a total absence of motion on breathing.

At first the patient may lie on one side or the other, but when the amount of fluid is great the patient lies on the affected side to allow free expansion of the other side. Rarely the interspaces between the ribs may be obliterated or even bulge from intra-thoracic pressure.

Palpation gives one very important sign,-absence of vocal fremitus. The patient is asked to speak loud and the voice vibrations, distinctly felt by the fingers on the normal side, are not transmitted to the fingers through the fluid on the affected side.

Percussion. As the fluid increases the percussion note becomes less resonant and finally flat. In the upper part usually the note is resonant over the retracted lung; below this the note is dull, and over the fluid, flat.

Auscultation. Friction is heard only at first when the wall and lung are in contact. The important sounds are those relating to the respiratory murmur and the voice. With small effusion the murmur is diminished. It may be tubular, but when there is much fluid the sound is not transmitted and nothing is heard.

Above, over the retracted lung, often the breathing is bronchial, and if the lung is compressed and does not work at all no murmur will be heard over the entire side.

fluid.

Voice sounds are diminished, or absent, transmitted through

Dislocation of the apex beat of the heart towards the sound side is an important sign in large accumulations only.

Absence of vocal fremitus, flatness on percussion, absence or decided lessening of respiratory murmur, are constant signs. Given such signs, exploratory puncture as a diagnostic measure should be made.

This little operation, without a local anesthetic, is often very painful and alarming to the patient. Its terror may be entirely avoided by the use of ethyl chloride spray and cocaine injection.

Sometimes it is desirable to make a second puncture if the first is unsuccessful. If the patient has been alarmed and frightened by the pain the second puncture may be a difficult undertaking for both physician and patient. The site selected should be sprayed with ethyl chloride until blanched. Then a sterile two per cent. solution of cocaine injected thoroughly into the skin and along the track the needle is to take to the pleura or through. The needle is withdrawn, and after waiting three minutes the aspirating needle can be deliberately and painlessly pushed in. This should always be connected with an exhausted bottle. If the fluid is found to be pus, an operation for drainage is indicated.

It is now recognized that it is best to resect a rib or even two ribs to give ample drainage, the space between the ribs not being sufficient.

In the operative province are several conditions to consider.

Robinson divides empyema into three classes,-acute, sub-acute, and chronic.

Acute empyema is where the disease has existed for a short time and the lung displaced by the fluid retains its expansibility unhindered by adhesions.

Sub-acute empyemas are those where either there has been insufficient drainage or where operation has been delayed and the lung has lost some of its expansibility and is somewhat adherent, though in neither case to such a degree that it cannot be induced to expand by suction persistently applied or by breaking up the adhesions. This can be supplemented by a course of suction, if necessary, at the wound, and blowing exercises by the mouth.

The third class, chronic empyemas, are those where the lung has lost its expansibility and has become permanently retracted and adherent.

We thus see that besides the mere opening to let out pus there are other mechanical conditions to be considered. Normally there is no empty space in the pleural cavity, as it is filled out by the lung. The viscual and parietal surfaces being in contact, glide freely on each other during the movements of inspiration and expiration. The elastic tissue of the lungs causes them to contract when fluid or air enters the pleural cavity. The fact that the lungs gradually expand when an opening from the outside for drainage is made is due to the fact that the opening has not the capacity of the bronchus. Each bronchus at the bifurcation has a diameter of about one-half inch.

When an opening is made through the wall, the lung contracts. A good-sized drainage tube is placed in the opening and covered with gauze. The pus soaks this gauze, and with each inspirating movement, as the thorax expands and the pleural capacity is increased, air rushes into the bronchus freely and is obstructed by the dressing at the wound. Gradually the lung, if not hindered by adhesions contracting and holding it firmly, getting more air through the trachea than the cavity through the wound, tends more and more to expand. As it does so it adheres more and more to the wall, and so gradually advances during convalescence until the space is filled.

When, owing to great delay, the lung coverings have become firm and less elastic and adhesions have formed, or the tube has been placed too high so the fluid does not drain, this favorable expansion does not proceed and progress stops. In such a case favorable drainage by a lower opening may be necessary. In any event, expansion may be helped by suction applied at the wound by a proper apparatus, and practiced daily.

Sometimes adhesions that hold the lung can be broken up and expansion then follows aided often by the suction scheme.

In the third case, with a firmly contracted, unexpanded lung, bound firmly by adhesions and the pleura converted to an old suppurated cavity, nothing can be done to induce expansion. Here, the use of the lung is lost permanently and our efforts are to be

directed to overcoming the suppurating process. This can be done only by some way of contracting the thorax so that it may fall in and obliterate the cavity.

This briefly is the story of empyema and its treatment.

The common operation is for acute empyema. The opening is usually best made in the posterior axillary line at the seventh or eighth rib. A three-inch cut is made directly down upon and along the rib. The periosteum is then quickly detached all around. from the rib and the denuded area of one and one-half inch resected. The pleura is then opened by pushing through a pair ch closed artery forceps which are then opened wide. The fluid pus gushes out. Not infrequently several large clots of fibrin float into the opening and plug it. These should be caught with forceps and pulled out. It is unnecessary to wash out the cavity, but its evacuation is assisted by turning the patient over so the pus flows down. A good sized drainage tube is inserted so its end is just within the pleural cavity, and fastened with a suture. The wound is then closed to the drain with one or two silkworm gut sutures on each side. A convenient tube is that of Wilson, which is of rubber and has a flange at each end to prevent its going in or coming

out.

An abundant gauze dressing is laid over this and retained by a binder. The after-treatment consists in changing the dressings frequently and getting the patient up as soon as possible.

In favorable cases there is no need for drainage after four or five weeks. Cases that have been operated upon and continue to drain pus and continue a temperature usually require an opening made lower, behind or near the original opening.

Suction applied daily to the wound, by a syringe attached to a glass bulb, will aid expansion; as will also getting the patient to blow the water from one bottle into another connected by tubes. Localized collections of pus are drained at whatever point they The operation is the same with drainage and dressing the wound until drainage ceases.

occur.

A WHOLE NATION VACCINATED.

Smallpox has been stamped out in Guatemala after a long epidemic, but only by the rigorous and unprecedented vaccination of every individual in the country. The whites have ever submitted voluntarily to vaccination; but the Indians, by reason of superstition, have heretofore always refused to be inoculated. Dr. J. A. Padilla, surgeon-general of the marine hospital and quarantine service of Guatemala, finding the epidemic beyond his control, made strong representations to President Cabrera of the necessity of immunizing the Indians, who were spreading the disease. The President then issued the order for general vaccination. Every physician in the republic was called on to assist, some thousands of dollars were invested in vaccine, and the soldiery concentrated the Indians. For three months the physicians worked daily. For the first time in its history (it is said) all Guatemalan ports are at present free from contagious diseases and passenger traffic is without restriction.-The Medical Times.

DEAN SUTHERLAND'S ADDRESS AT THE OPENING OF THE THIRTY-NINTH ANNUAL SESSION OF BOSTON

UNIVERSITY SCHOOL OF MEDICINE.

Ladies and Gentlemen:·

Time relentlessly pursues the even tenor of its way undisturbed by the happiness or misery, the prosperity or failure, the diligence or shiftlessness, the interest or indifference of mankind. Morning and evening, summer and winter follow each other in established order and come and go quite irrespective of the desires or condition of humanity. In anticipation four months may seem a long period of time; in retrospect it not infrequently seems as "but a passing breath." For the majority of us a summer has intervened, a period of four months has joined the irrecoverable past since we last met in these halls. What has this period of time meant to us; in what fashion has it been utilized to our advantage; what changes has it introduced into our common environment; what preparation for our work in life has it enabled us to make? These and questions of a similar nature naturally occur to us as, after a vacation period, we gather here to participate in the opening exercises of a new School year; and perhaps it may be profitable for us briefly to consider some of the topics suggested by such questions and the occasion itself.

First of all let me extend to you one and all, individually and collectively as classes, to old friends and to new comers, (prospective friends), the heartiest greetings and most cordial welcome. This it gives me great pleasure to do personally and as one of your instructors; this it is my highly-prized privilege and duty to do as the representative of the Faculty of Boston University School of Medicine. As the doors to these halls have been opened to you today and you are bidden to enter, so the doors to our fraternal regard, assistance, coöperation and friendship are thrown wide open and you are sincerely invited to enter. To reach its highest efficiency our relationship must be more than that traditionally existing between teachers and pupils, we must work together in a spirit of mutual toleration, confidence and sympathy as we probe into the mysteries of life revealed in our studies of anatomy, physiology, pathology and related sciences, and as we try to fit ourselves for the intricate and arduous labors connected with the age-old Art of Healing. We welcome you at the threshold of a noble profession, and we shall expect to welcome you before long as colleagues in that profession.

It is unnecessary to remind you that this is the first day of a new year with all the possibilities which are offered by a new and fresh beginning. Profiting by past experiences we can by a resolute effort make of the new school year a success that shall far surpass in solid and useful accomplishment any of its predecessors. Its predecessors are becoming steadily more numerous, for this is the opening day of the thirty-ninth session of our School. It is significant in that it is the last year of the