NEW YORK.

MAJOR M. R. C., U. S. ARMY.

In the War Demonstration Hospital at the Rockefeller Institute for Medical Research we have treated a number of cases of empyema following pneumonia. As many of these cases have been of a peculiar type an entirely new problem has been presented. All have been treated with the Carrel-Dakin method. These cases had first been admitted to the Rockefeller Hospital as pneumonia cases and then transferred to the War Demonstration Hospital after the development of empyema.

As this is to be a discussion on treatment, I will merely mention that the usual physical examinations, x-ray, thoracic punctures, and cultures of the pleural fluid, were employed in all cases for diagnostic purposes. The case was considered one of empyema if on thoracic puncture macroscopic pus was found, or if pus cells and organisms were demonstrated by the microscope.

This evidence was considered sufficient for operation, and some cases were operated on as early as the third day after the onset of the pneumonia. The longest period which elapsed before operation was 120 days. This patient has been aspirated in another hospital seven times. Our operations were performed under local anesthesia, novocaine 1:400. The operation of choice has been rib resection, opening into the pleural cavity and exploration with the gloved finger or instrument, opening all pockets. The site of operation in those cases where the fluid seemed to be evenly distributed has been at the lowest point posteriorly, and in most cases over the eighth or ninth rib in the posterior axillary or scapular line. In those cases where a definite localized pocket was found the opening was made over the region of the pus.

In the early cases the pleural cavity was not flushed out at operation. Three to five Carrel perforated tubes were placed in the cavity extending to all points, and two large short tubes inserted in order to have a free outflow of secretion and chlorinated material. With our later cases the pleural cavity has been flushed with Dakin solution at the time of operation, the large tubes have been omitted and four Carrel tubes stiffened with fine silver wire have been placed,endeavoring to reach all parts of the cavity. Compresses wet with Dakin solution, replaced the large tubes originally used, in order to prevent a too rapid interchange of air. After placing the tubes and compresses, x-ray examination showed that the tubes reached all parts of the cavity.

In the early cases instillations of 30 to 60 cc. of 0.2 per cent, sodium hypochlorite solution were given every two hours for forty-eight hours, and as no contraindications arose in the use of this solution the strength was increased to 0.5 per cent, sodium hypochlorite, or full-strength Dakin solution. In our later cases instillations have been given every hour during the day and every two hours during the night, and the amount has been increased to from 80 to 100 c.c. Dakin solution. This has been done to follow more closely the necessary principles of time, concentration, and contact in the use of an antiseptic.

Dressings are made daily. A smear from the inside of the pleural cavity is taken to be examined microscopically, the cavity is flushed out, the individual tubes are tested, and fresh tubes inserted when necessary. Compresses wet with Dakin solution are then placed in the external wound as at operation, the skin is protected with vaseline compresses or zinc oxide ointment, and a cotton pad and chest binder applied. The external dressings are changed by the nurse when necessary.

In our first cases closure took place spontaneously in from three to seven weeks, no attempt being made to suture the wounds. In the later cases, however, we have made secondary closure with suture when sterilization was obtained as shown by the bacteriological curve, and in some cases by culture as well. Cultures taken at the time of dressing have been found sterile at the end of five to nine days. In this way we were able to close cases in from five to twelve days or more, the average time being about fourteen days. Primary union was obtained in about 70 per cent, of the cases. When secondary sterilization was necessary this was readily obtained in all cases in a week or less, and complete closure was the finalresult. The secondary infections were always found to be of a low virulence.

After operation the patients were comfortable and were, in general, free from the toxic symptoms present in most empyema cases. The secretions have been small in amount and free from odor. The temperature has dropped, as a rule, after operation, and in a few cases where it has remained elevated this has been due to the pneumonic process which was still active, or else to complications, since practically all of our cases were operated upon before a crisis or lysis.

We have treated up to the present time forty-five cases. With the exception of five of these cases the entire treatment was carried out in our hospital. These five cases were sent to us from other hospitals with sinuses that had been discharging from three days to three months. The ages of the patients have varied from fifteen to sixty-eight years. We have had thirty-two cases of streptococcus infection, nine cases of pneumococcus infection, and four cases in which it was impossible to isolate any one type of organism.

At operation we have found in the great majority of cases the fluid to be perfectly free in the pleural cavity. The character of the fluid was usually thin and watery, of a greenish, yellowish, or brownish color, and in some few cases thick, creamy pus. In a number of cases a large amount of fibrin was present, covering the pleural surfaces, and with irrigation large shreds were washed away.

Complications other than those to be mentioned in autopsy findings have been three cases of abscess of the buttocks, three cases of acute tonsillitis, and one case of scarlet fever. We have had twelve deaths in this series, nine of -which have been of the streptococcus groups. At autopsy we have found pericarditis in five cases, together with one or more of the following lesions: cervical adenitis, mediastinitis, miliary tuberculosis, intestinal ulcerations, peritonitis, numerous small lung abscesses, and small kidney abscesses; one case of general tuberculosis, three cases with pneumonia involving the opposite lung, and a beginning fibrinous pleurisy. In three cases we were unable to obtain autopsies and cannot state the exact condition present.

No case has been discharged from the hospital with a sinus. All wounds have healed clean and solid. Chest examination has shown the lung to be practically normal, judging from physical and x-ray examinations. We have been able to return cases to duty in twenty-one days after operation. One case had pneumonia, empyema, operation, sterilization, closure, and was ready for duty in twenty-six days. The average length of time in the hospital after operation has been fifty days. This seems rather long, but we have often kept cases several weeks for demonstrative purposes. Not a case, to our knowledge, has been discharged from the Army or Navy for physical disability. All have gained in weight - one as high as 36 pounds. We have discharged in all twenty-two cases and some of our soldiers are now in France.

In this small series of cases, summarized in a brief preliminary report, we have found it possible to use the Carrel-Dakin method of treatment of empyemas with very satisfactory results when careful attention has been paid to all the details of its application. The series of cases has not been large, but the ultimate results obtained - forty-five cases treated, twelve deaths, eleven still in the hospital under treatment (five of which are about ready for discharge), and twenty-two cases discharged, the comparatively short stay of patients in the hospital, and their ability to return to active duty - well demonstrate the value of the method in the treatment of empyema cases.