Principles in the management of pulmonary abscess

PRINCIPLES

IN THE MANAGEMENT

OF PULMONARY

ABSCESS* REEVE H. BETTS, M.D. BOSTON, MASSACHUSETTS

E

excIuded. Certain of the rare conditions such as infections due to FriedIander’s baciIIus or to fungi are not within the scope of this discussion. It does incIude, however, a11 other types and no effort has been made to consider separateIy various cIass&ations such as acute or chronic, simpIe or compIicated, putrid or aputrid, IocaIized or diffuse, singIe or muItiIocuIar, or pulmonary gangrene. The underIying pathoIogicaI process is the same in each instance; and aIthough the manifestations may differ, the principIe of earIy adequate drainage has been foIIowed in aI1. However, the fuIminating diffuse Iesions or the frankIy gangrenous processes wiI1 not yieId as good resuIts as are obtained in the treatment of earIy, acute, singIe abscesses.

XCLUDING neopIasm, puImonary abscess is one of the most serious diseases of the Iung. The mortaIity in reported series ranges from 30 to 50 per cent. Sweet’ reported a mortahty rate of 34 per cent in 124 cases; CutIer and Gross2 reported 38 per cent in eighty-five cases; Brunn3 reported 60 per cent in 205 cases. Many other patients who did not actuaIIy die in the hospita1 were Ieft as chronic puImonary invaIids due to irreparabIe damage to the Iung by the infectious process. It is rare to find a reported cure rate of 50 per cent or over. In the past few years, Neuhof and associates,4’5’6 and OverhoIt and RumeI’ have shown markedIy improved resuIts in acute cases treated by prompt surgica1 drainage. Neuhof6 and his group had four deaths in 104 acute whiIe OverhoIt and RumeI’ abscesses, reported two deaths in thirty-five “SimpIe” (mostIy acute) abscesses. Even more important was a cure rate of 94 per cent in OverhoIt and RumeI’s series. It is the purpose of this paper to add evidence to that contained in the recent reports, to indicate a broadening of the indications for surgica1 treatment, and to support the view that puImonary abscess shouId be considered primariIy a surgica1 disease from its onset. ConcIusions are based upon twenty-five consecutive cases treated by the author with but one operative death.

BACTERIOLOGY

The bacteria1 flora of puImonary abscess is variabIe. UsuaIIy a mixture of staphylococci and streptococci is found with frequent other associates. Both aerobic and anaerobic organisms are present in most instances. Specific therapy either with neoarsphenamine or one of the suIfonamide drugs has been disappointing, and bacterioIogy for the present has been reIegated to a pIace of minor importance. DetaiIs of treatment may have to be varied according to the etioIogica1 organism but the principies of treatment are the same for a11 types. It appears that most of the destructive and necrotizing organisms are either strict or facuItative anaerobes. Reports on the bacterioIogy, unIess incIuding careful anaerobic cuItures, are not significant. Many abscesses wiI1 be found to contain steriIe pus if onIy aerobic cuItures are taken. Although some of the organisms are very

DEFINITION

PuImonary abscesses due to the tubercIe baciIIus or secondary to neopIasms are not incIuded in this study. Likewise, muItipIe Iesions on a definiteIy bronchiectatic basis or as a part of a generaIized pyemia are * From the New EngIand Deaconess 82

HospitaI,

Boston,

Massachusetts.

Betts-Pulmonary

New SERIES VOL. LIV, No. I

viruIent under certain conditions, many are easiIy destroyed by an unfavorable environment. Studies of these organisms

Abscess

American

Journal

of Surgery

83

Iectomy or tooth extraction. Some abscesses folIow pneumonia, especiaIIy if the pneumanic process is due to a staphyIococcus.

FIG. I. A diagramatic drawing iIIustrating the close proximity of the pulmonary and bronchial arteries to the corresponding bronchus.

must take such factors into account. It is our practice to aspirate secretions from the abscess into a test tube at operation. This materia1 is then transferred immediateIy to a thermos bottIe and kept at body temperature until it reaches the Iaboratory and is pIated on various media. Such cuItures most aIways show a mixture of organisms with staphyIococci and streptococci predominating. Vincent’s organisms may be recovered from the gums of a patient with a Iung abscess, but they are not frequentIy encountered in the abscess cavity itself. PATHOLOGY

We subscribe to the beIief that aspiration of infected materia1 into a bronchus is the primary cause of most puImonary abscesses.8sg*10This materia1 may be inhaIed from infected gums during sIeep or at operation. It may be detritus at the time of tonsil-

AIthough other factors, such as a septic emboIus, are occasionaIIy responsibIe, it seems IikeIy that a11 but the exceptiona case are due to aspiration. When the bronchia Iumen to a segment of Iung becomes occIuded, the portion of Iung beyond becomes ateIectatic and a perfect environment for anaerobic organisms is estabIished. The spread of infection to the peribronchia1 structures impairs the brood suppIy to the segment beyond and hence in the course of a few days the area may become necrotic and symptoms of Iung abscess appear. The cIose reIationship of the bronchus and bIood supply to a pulmonary IobuIe is shown diagrammaticaIIy in Figure I. PeribronchiaI infection need not be extensive to incIude the accompanying branch of the puImonary artery. Mathes, HoIman and Reichert” found that bronchia occIusion in the dog was universaIIy fatal unIess the foreign body

84

American

Journal

of Surgery

Betts-PuImonary

(sponge) was removed. Likewise puImonary emboIus aIthough we11 toIerated in the absence of infection was aIways foIIowed by abscess formation in the presence of infection. A septic bronchia obstruction by extension of the infection to the accompanying pulmonary artery resuIting in thrombus formation can provide this serious combination. Infection in a puImonary segment caIIs forth the usua1 protective inflammatory waI1. This protective waI1 is seen on inspecting the interior of the abscess cavity at operation and is further evidenced by the aImost universa1 finding of pIeura1 symphysis over the periphera1 portion of the abscess. When this protective process is not sufficient, extension of the necrotizing puImonary process to the surface of the Iobe resuIts in empyema. PuImonary abscess is a segmenta Iesion as shown by GIass. l2 The causative factor is Iocated centraIIy and is the source of the diminished bIood suppIy to the periphera1 portion of the segment. PuImonary arteries are end arteries, thus the periphery of a IobuIe has the poorest bIood suppIy. This region, therefore, is the first to undergo dissoIution and the abscess first becomes manifest in this area. The periphery of the IobuIe forms the periphery of the Iobe, thus abscesses due to bronchia occIusion must be in contact with either the chest waI1, interIobar fissure, diaphragm or mediastinum. Abscesses which have been referred to as “centra1” are those not facing the IateraI chest waI1, or are so Iocated as to project “ centraIIy ” on the posteroanterior roentgenogram. BASIS

FOR

EARLY

SURGICAL

DRAINAGE

A certain percentage of Iung abscesses wiI1 regress spontaneousIy and many of these may give no further symptoms after a period of medica management. The exact number that wiI1 do so is undeterminabIe but it is probabIy in the vicinity of 20 to 35 per cent. MedicaI management incIudes a good hygienic rkgime with postura1 drainage, medicaments, broncho-

Abscess scopic aspiration and pneumothorax. The Iatter, however, has been aImost abandoned due to the high incidence of serious or even fatal compIications. Reported series incIude King and Lord’s report;‘” 40 per cent of the patients were cured and the mortaIity was 35 per cent among those treated medicaIIy. RosenbIatt14 reports 7 per cent cured and 47 per cent dead. Jackson and Judd8 report 42 per cent cured and 29 per cent dead by medical measures incIuding bronchoscopy. However, in the series of Jackson and Judd there were thirty-seven other patients who were referred for surgica1 treatment, eighteen or 48 per cent of whom died, making a true mortaIity rate of 36 per cent for the whoIe series. When medica management should cease in a given case and surgica1 treatment be instituted is a diffIcuIt question to decide. Most authors favor a period of six weeks to three months before considering surgica1 drainage. The resuIts of surgery in such a group are IikeIy to be poor, as those patients have suffered the effects of a Iong septic iIIness. CutIer and Gross2 reported a mortaIity of 38 per cent in their group of eighty-five surgica1 cases, and AIIen and BIackman15 reported a mortaIity of 30 per cent in ninety-four cases. These figures based as they are on a group of poor risk patients after protracted medica management do not give a true picture of the possibIe surgica1 resuIts. Assuming that of one hundred cases of lung abscess, thirty wiI1 recover spontaneousIy and 60 per cent of the remaining seventy wiI1 get we11 foIIowing surgery, it stiI1 Ieaves a 28 per cent mortaIity for the group as a whoIe. No one can predict which case wiI1 hea spontaneousIy or when a given case wiI1 become complicated. If surgery can cure more than 72 per cent of the group as a whoIe by operating upon a11 patients earIy in the disease, it wouId be better to operate upon a11 as in the end more patients would be Iiving and weI1. The same Iine of reasoning applies to the time at which operation shouId be carried out. If one cannot foreteI1 with

NEW

Smras

VOL. LIV.

No.

I

Betts-PuImonary

certainty the stage at which complications wiII deveIop, a11 patients should be operated upon before any enter the compIicated state. Rives, Major and Romano16 in a study of one hundred fata cases reported that 74 .per cent of that group were frankly hopeIess within one month of the time of onset. Sweet’ reported four deaths out of eleven patients operated upon who had entered the hospita1 within four weeks of onset. He further states that “of 14 cases in which death occurred without operation, IO died in Iess than 2 months after the onset of the disease.” Jackson and Judd8 found that eIeven of twenty-five deaths occurring on “ conservative ” therapy were within two months of onset. The principIes of drainage of puImonary abscess are essentiaIIy those which appIy to an abscess in any other Iocation. These are thorough and adequate drainage of the process at the earIiest time and with as IittIe disturbance of surrounding norma structures as possibIe. The smaI1 and inconstant Iumen of an inflamed bronchus does not provide adequate drainage for a puImonary abscess. A smaI1 opening of a comparative size wouId be considered whoIIy inadequate for an abscess Iocated eIsewhere. The frequent finding of a Iarge amount of thick inspissated materia1 within the abscess at the time of operation is further proof of the inadequacy of bronchia1 drainage. How can open drainage be provided with safety? It is necessary to take advantage of the superficia1 Iocation of the Iesion and the adhesions formed by the process. This can be done if there is accurate roentgenoIogica1 IocaIization. ROENTGENOLOGICAL

LOCALIZATION

Accurate preoperative roentgenographic IocaIization is vitaIIy important. PIeuraI symphysis is most secure and extensive over that portion of the abscess that is nearest the periphery. This site must be determined roentgenoIogicaIIy. PreIiminary ffuoroscopic study wiI1 aid in determining the most advantageous position for taking the roentgenographic

Abscess

American

Journal

of Surgery

89

pIates. Postero-anterior, IateraI and anterior obIique views wiI1 usuaIIy be suff~cient. It may be necessary to suppIement these conventiona views by overexposed or Bucky fiIms, or projections of varying obIiquity. After the location of the abscess has been determined, its exact reIationship to the chest waI1 should be checked by a repeated series of fiIms after pIacing an appropriate radio-opaque marker. In pIacing this marker aIIowance for the shift of the chest waI1 structures must be made. The marker shouId be placed with the patient in the same position he wiI1 assume upon the operating tabIe. Neuhof’s practice of injecting a mixture composed of 2 to 3 m. of IipiodaI and a dye into the intercostal muscIes is heIpfu1. The Iipiodal wiI1 be seen on the fiIms and the dye provides a visible Iandmark at operation. We have found that Iamp black is more suitabIe than some of the dyes in that it remains visibIe in the tissues for a Ionger time. ONE-STAGE

OPERATION

PREFERABLE

The possibiIity of contamination of the pIeura1 space or a dessicating infection of chest waI1 structures are advanced as reasons for empIoying a two-stage procedure. It has been found by Neuhof,4’5 OverhoIt and RumeI,7 and confirmed by our own observations that if the abscess faces the thoracic cage, pIeura1 symphysis wiI1 be found if the Iesion is properIy IocaIized. The area of adherence may not be Iarge but wiI1 be sufficient for safe drainage. It is interesting to note that in the report of OverhoIt and RumeI’ empyema occurred as a postoperative compIication four times as often after the two-stage drainage as after a one-stage procedure. By seaIing off the fascia1 pIanes as described beIow, the fear of a dissecting ceIIuIitus is more theoretica than practica1. By obviating the former objections to the one-stage procedure this method becomes appIicabIe to a11 abscesses except those facing an interIobar fissure, the diaphragm or medi-

86

American

JoumaI

of Surgcrg

Betts-PuImonary

astinum when chest wall adhesions may not be present. The Iapse of time between stages of a two-stage procedure may be hazardous. Even shortening the usua1 interva1 to onIy one or two days does not remove the risk. Occasionahy, the first stage operation is folIowed by an exacerbation of the process or an extensive spread, thus converting a simple lesion to a complicated probIem. ANESTHESIA

It is our practice to employ procaine hydrochloride paravertebral block pIus Iocal infiItration. Caution must be exercised to prevent spiIl-over of puruIent material to other parts of the same lung or to the contraIateral Iung during operation. It is usuaIly necessary to have the patient lie with the affected lung uppermost thus favoring “crossfire” spread. Such a compIication can be minimized by use of a rather steep Trendelenburg position and close observation by the anesthetist, who should encourage the patient to cough and raise any material that may drain into the tracheobronchial tree. The use of positive pressure oxygen administered by means of a properly fitted face mask provides a further safeguard. This is begun as soon as the chest wal1 drainage path has been prepared. Maintenance of positive intrabronchial pressure causes air to flow from the interior of the tracheobronchia1 tree toward the exterior through the bronchial hstula communicating with the drainage tract. This bIows any discharge from the abscess outward rather than alIowing it to drain internahy. Maintenance of the positive intrabronchia1 pressure furthermore tends to keep the periphery of the Iung and the chest waI1 in apposition and Iessens the Iikelihood of tearing friabIe pIeura1 adhesions. The positive pressure is maintained unti1 the abscess is drained, packed, the dressing applied, and the patient placed upon his operated side.

Abscess OPERATIVE

TECIINIC

The patient is pIaced on the table so that the site for the incision is convenientIy located. Marked TrendeIenburg position is used to favor drainage of bronchia secretions and to minimize the possibiIity of cerebral air emboIism. The site of incision depends entireIy on the location of the most periphera1 portion of the abscess. It is placed so as to expose the rib directly over the center of the Iesion. A &e-inch skin incision is usuaIIy sufficient. If the operative held is in the axilla, a Y-shaped incision may be used to advantage as this prevents too rapid closure of the chest wall structures. The skin and subcutaneous tissues and muscles are divided down to the underlying ribs. A four-inch segment of the rib is subperiosteaIly resected, the ends sealed with bone wax and the corresponding intercosta1 bundIe is ligated at either end. The intercosta1 nerve accompanying the rib above is crushed. With a continuous suture of fine chromic catgut, the subcutaneous fascia and intercosta1 structures are approximated so as to seal off al1 fascial planes. (Fig. 2.) At this point the anesthetist begins the administration of oxygen under moderate positive pressure so as to keep the Iung and chest wal1 in apposition. An incision is made through the periostea1 bed unti1 the Iung is encountered. This establishes by actua1 inspection the presence or absence of pleural adhesions. If they are found, one may proceed with drainage. If not, localization has probabiy been inaccurate or the Iesion does not point on the chest waI1. It is wise then to pIace a piece of gauze with a metal marker attached, such as a Michel skin clip, in the incision, pack the wound and re-examine the patient roentgenographicaIly to check the IocaIization. If adhesions are present, a 17 or 18 gauge needIe attached to a syringe is introduced I to 2 cm. into the underlying Iung. If the IocaIization is correct, pus or foul-smeIling air should be obtained immediately. The needIe is left in pIace as a guide and with the actual cautery a

NEW SERIES VOL. LIV, No. I

Betts-Pulmonary

moderate-sized opening is made in the waI1 of the abscess. (Fig. 3.) Large openings are to be avoided as they may extend beyond

FIG. 2. Drawing to show suturing of subcutaneous fascia to the periosteat bed. A segment of rib has been subperiosteally resected. The accompanying intercostal vein, artery and nerve have been ligated and divided.

Abscess

American Journal of Surgery

87

A piece of rubber dam with an opening to aIIow drainage is sewn to the edge of the drainage tract to make subsequent dress-

t2l

_+1

FIG. 4. Drawing

iIIustrating the use of rubber dam to prevent adherence of the gauze pack to the wound. The rubber dam is sewn down to the intercostal structures.

FIG. 3. Opening of the abscess with the cautery after aspiration with a needIe. Note the sucker which removes smoke from the operative field and prevents spilIage of the contents of the cavity.

the zone of pIeura1 adhesions. A suction tube removes smoke from the operative fieId, and prevents gross contamination of the wound by the contents of the cavity. The cavity is evacuated with the sucker and materia1 obtained for cuIture. With as IittIe manipuIation as possibIe, the cavity is cIeaned out and packed IightIy with dry gauze. It is our practice to pIace 4 to 5 Cm. of powdered suIfathiazoIe into the abscess, and another I to 2 Gm. are sprinkled into the wound to discourage bacteria1 growth.

FIG. 5. Illustrating the method of preparing a safe drainage tract for an abscess pointing on the diaphragm. A segment of rib has been removed. The gauze pack inserted to the border of the abscess wiII cause adhesions to form, thus sealing off the pleura1 space.

ings easy to change. (Fig. 4.) This prevents the gauze pack from becoming adherent to the skin and subcutaneous structures. A dressing is appIied and the patient turned upon the operated side, and then and only

88

then is the discontinued. TECHNIC

Betts-PuImonary

Amer~an Journal ol Surgery

FOR

positive ABSCESSES THORACIC

pressure NOT

oxygen

FACING

THE

WALL

Abscesses facing the interlobar fissure, diaphragm or mediastinum may demand a two-stage drainage in order to provide a safe drainage tract through a nonadherent The site of drainage is pIeura1 space. seIected that is nearest to the underIying abscess. The operation is carried out as in the one-stage procedure to and incIuding the incision of the pIeura. The Costa1 pleura may be found nonadherent. The space between the chest waI1 and the abscess is packed with a strip of gauze as iIIustrated in Figure 5. Two to five days Iater, the pack is removed and the abscess opened and treated as in the one-stage operation. MULTIPLE

ABSCESSES

Many abscesses become muItiIocuIated. If the IocuIations a11 originated as direct extensions from the origina process, they wil1 be found to communicate with the main cavity and thus a11 may be drained at one time. In some cases adequate drainage may not be obtained and subsequent cauterization becomes necessary. This usuaIIy can be carried out through the origina approach. PuImonary suppuration following staphyIococcic pneumonia may present a compIicated probIem. One or more segments of the Iobe usuaIIy contain multipIe abscesses fiIIed with thick, aImost geIatinous pus which drain poorIy through the bronchi. The entire segment may have to be destroyed by repeated cauterizations. This may necessitate an approach from more than one avenue. Distinct muItipIe abscesses in separate parts of the same Iobe or in different Iobes wiI1 be found in some cases when first observed. (See Cases I I, 12, 16, 19 and 21.) These must be drained through separate approaches at separate operations, attacking the Iargest or most acute process first. In specia1 instances in which the process is of Iong duration with marked puImonary fibrosis and accompanied by extensive

Abscess bronchiestasis, resection of the invoIved lobe or lung may be indicated. In generaI, the resuIts of Iung resection for acute abscesses are encouraging but stiI1 entaiI a quite high mortality. Iv7 PreIiminary drainage to enabIe the patient to improve may be a necessary first step.i POSTOPERATIVE

MANAGEMENT

Care of the operative site is most important. In general, the origina dressing is left in pIace from four to seven days. Plain dry gauze seems to be the best packing material. If the secretions are malodorous, the responsible anaerobic organisms can be quickIy brought under contro1 by packing the cavity daiIy for a few days with gauze soaked in zinc peroxide. The frequency of change of the pack is determined by the amount and character of the discharge. Dusting the inside of the abscess with suIfathiazoIe has been found effective in combatting bacteria1 growth. As the heaIing process progresses, the waI1s of the cavity cIose in and when it becomes too smaI1 to pack easily, a soft rubber tube is inserted and fastened secureIy in pIace with adhesive strips to a safety pin which is passed through the end of the tube. The caIiber of the tube can be diminished as the sinus decreases in diameter. Withdrawa of the tube is not to be hurried. It may take severa months for the heaIing process to be compIeted. The tube shouId not be Iess than I or 2 cm. shorter than the sinus. It must be Ieft in pIace unti1 the bronchia IistuIa has closed. This wiI1 take place spontaneousIy in a11 but a very few cases. After waiting severa months, it may be necessary to resort to a muscIe pIastic closure of the bronchia hstuIa. This rareIy has been found to be necessary in our cases. In no instance in which it has been used has it faiIed to produce permanent cIosure of the fistuIa with resuItant soIid chest waI1 heaIing. AVOIDANCE

OF

COMPLICATIONS

CompIications are usuaIIy due to an inaccurate approach to the Iesion. This

NEW SERIES VOL.LIV, No. I

Betts-PuImonary

may resuIt in either pleural contamination or in compIications due to approaching the abscess through a portion of normaI Iung tissue, or both. Finding extensive pIeura1 adhesions may Iead to the faIse beIief that one has accurateIy IocaIized the abscess because adhesions may be present which bear no reIation to the abscess. If one cannot obtain pus or fou1 air on aspiration, extreme caution shouId be exercised, and in most instances further x-ray studies are in order. EstabIishing a drainage tract through norma Iung parenchyma opens fresh tissue to infection and increases the danger of air emboIus. Our findings bear out Neuhof’s4 statement that the most superficia1 portion of the cavity waI1 is avascuIar. The abscess may be opened in this area without danger of air emboIus. RESULTS

The resuIts of surgica1 treatment of Iung abscess based upon a consecutive series of twenty-five* patients treated by the author are summarized in TabIe I. There were twenty-four recoveries with one death (4.0 per cent). AI1 patients except the one fata case showed marked improvement as soon as adequate externa1 drainage was provided. Postoperative empyema did not occur in any case in which one-stage drainage was used. A dissecting infection of the chest waI1 did not deveIop in any case. Cerebra1 air emboIism was not encountered. Five patients (Cases I I, 12, 16, Ig and 21) had two or more separate and distinct abscesses requiring separate operations. In four instances, (Cases I I, I 2, I 6 and 2 I) the Iesions were in different Iobes. The one fata case had muItipIe abscesses in a11 five Iobes. The time from onset of symptoms to drainage varied from one to sixty weeks. In ten cases, the duration of symptoms was six weeks or Iess. The one fata case (Case 21) was of five weeks’ duration. It is quite IikeIy he wouId have survived had drainage been provided before a massive spread *The first twenty in a previous report.?

cases in this’series

were included

Abscess

American Journal of Surgery

89

iIIustrates the took pIace. Th is patient falIacy of waiting any specified time before instituting surgica1 treatment. One-fourth of the abscesses (six patients) foIIowed tonsiIIectomy. This is a high percentage, but was assigned as the cause onIy when the evidence was irrefutabIe. Excluding the fata case, one patient who was transferred to a psychopathic hospital, and two who are stiI1 under observation, the average period of hospitaIization foIIowing drainage was forty-five days. This is in marked contrast to the duration of hospitalization on a medica or a combined medica and surgica1 rCtgime. Brunn3 reported the average duration of hospitaIization in his coIIected series of patients under combined medica and surgical management as 154 days. Of the abscesses facing the thoracic cage, adhesions were found in a11 instances when Iocalization was correct. Note in TabIe I that the two-stage operation was suppIanted by the singIe procedure in the more recent cases as greater attention was paid to accurate roentgenoIogica1 IocaIization. Likewise, the number of cauterizations was reduced and has approached the desired IeveI of one per patient. Four detaiIed case histories iIIustrating different types of abscesses encountered, incIuding the one fata case, are presented beIow. CASE

REPORTS

Jr., a forty year oId male, married, insurance salesman, was admitted to the New England Deaconess HospitaI on September 26, 1940, with a chief compIaint CASE 21.

Mr.

J. D.,

of cough, expectoration, dyspnea, paIpitation and a loss of twenty-two pounds in weight. Six weeks before admission the patient had been operated upon for chronic appendicitis under ether anesthesia. The postoperative convaIescence was uneventfu1. However, the patient faiIed to regain strength. He was discharged on the tweIfth postoperative day. Two days Iater he began to cough and raise Iarge amounts of greenish, fouI-smeIIing sputum, and noticed a duI1 ache in the Ieft side of the chest. BIood in the sputum was seen on three occa-

9

1”

-

7

5

4

3

i’

--

_

__

M

c.

E. M

--

T.

R. T.

r. P.

1P. s.

1L. J.

1E.

4. B.

t3. H.

K.

2

,.

a

4

B

-.

2

-

-

.P

I

VI

s? : t 2 ._ ki

- -

2

d,

4

2 i

0

10-6-38

9-24-38

7-6-38

5-27-38

s-29-39

S-24-39

5-I z-39

-_

4-17-39

I I-21-31

Z-25-39

I I-12-31

__

-

--8M

42M

5°F

56M

53M

ZZM

$3 F

---

14F

--.-

$9 M

35 M

6

5

7

21

9

I+

36

56

48

2”

sepsis

Postop. T and A

Postop. pendect”::

Postpneum

Oral

Post convulsion

Unknown

Unknown

Postop. T. and A

c’

+:

+-I

+-

-+t -_ +-

zf +-+t -_ +-+t -._ +-

2;

: ;

tion

-

-

-

Cavity Loca-

X-ray Examination

wall

Chest

Chest

Chest

Chest

Fissure

Chest

Chest

wall

wall

wall

wall

wall

wall

--

--

Chest wal I and fissure

Chest

L

:

1

c

--

--

-~

--

-_

-

T

- _._

-

_

-

-

-

-

:c

;z)

)

!

I CASES

jtaph. Albus Hemoly.

‘

‘

Staph.

. .

.

Unclass. bacilli

__-

Staph. AUXUS

Staph. AUXUS

Staph. AUXUS

Hemoly. Swept.

“:;wb,“,u,

No growth

__

I_

organ Staph

No growth

AUVXS Hemoly.

vhmc~Pt’s

Staph. Aureus

jpirochetes Staph. Aureus

jpirochetes and fusiforms, Staph. Aureus

staph. Aureus Hemoly.

I_Amrofs. ”


jtaph. AUXUS

I-

Bacteriology

I‘40 growth

‘

,-

nE I E2 : 50.

- -

OF

TABLE SUMMARY

.

--

--

drainage

stage

drainage

One stage drainage

Drain. empyema and abscess

IOne

,One stage drainage

,One stage

Two stage drainage

Two stage drainage

Two stage drainage

,3ne stage drainage

rhoracotomy subsequent drainage

IE;xh

I-

+

-

-

“P.

prl?-

ent

PPX-

I_

-

_

+ -

34

28

28

81

26

56

13

74

52

_ _

_

_ _

-t

_ _

_ _ _ _ _

_ _

3

0

4

2

Does

At-

No symptoms. tending school.

At-

pulWorking. No monary syn~ptoms.

I~oes own housework. and Bronchoscopy bronchography. 10/p/40 showed no patholpulmonary

Xed 11/7/39 of hypertensive cardiovascular disease. Had no post-op. pulmonary symptoms.

Vo. pulmonary symptoms when last seen 3/39. Mental symptoms continue.

Tollowing 1st operation had recurrence of abscess. Redrained. Empyema. Prolonged hospitalization. Working full time ns truck driver. Is asymptomatic.

\symptomntic. own housework.

,-

symptoms. \I” tcndina school.

Norking. Has bronchial fistula without drainage. Refuses to have it closed.

iNas well and working ;;kez”b,ast seen 3/39. to follow since.

Comments and Present Status’

7: 3.

M.

4-5-41

_

_

if

I -

!

6

3

20

3

20

5

160

36

A’

-

Postop. cholecysrectomy

ex-

I

Postpneumonit

Unknown

Postappendectomy

p,qs:

ex-

Postteeth traction

-

sepsis

Unknown

Oral

Postco”““lsive

Unknown

Dental traction

._

_

Oral sepsis p1.w accxdent with unconsciousness

Unknown

Unknown

_.

13

2

6

5

1 I2 _

_

-

_

7

*As of June 1, 1941. t Case reporred in detail.

7H.

,33, F

4-12-41

,c.

v.

.-_ 3, F

~ r-30-41

V. G.

7

t

39 M

‘a-3-4o

77K

Jr.

40 M

~__ 9-26-40

D.

s8 M

S-28-40

1L.

38 M

52 M

47 M

!I

12 M

___-_ 7-29-40

--_ 7-20-40

z-27-41

5-23-40

___--

s-14-40

32 M

58 M

33 M I

38 M I

G. D.

_

A. C.

_-

H. C.

_-

w. G.

___-_ r-15-4.o

__--

_c. w.

,-2I-*o

__-_ ro-28-39

9-Z-40

--_ ro-18-39

__-r-g-40

G.

E.

_-

F.

_-

_.. c.

2-16-40

18

+

_

-

_

_

--

_

_

/-

I-

I_ I

_ _

I--

-c

_ -

_

(2)

T-

-

-

+

-I

-I-

wall

wall

wall

wall

i Zhcst

i Zhest

(lhest

,Chest

fissure

( -hat

wall

i .nterlobar

wall

wall

wall

wall

wall

7Chest-

,Chest

,Chest

Mediastinun

,Chest

Chest

~7-hat

-

wall

wall

wall fissure

1-

I_

Chest wall I and fissure

Chest

Chest

Chest and

Proteus

fusiform

Strep.

strep. viridans B. Coli

Diphtheroids

No growth

B. Coli bacilli

B. Coli

bacilli

Aureus

Diptheroids

B. Coli

B. Coli

Fusiform

Staph.

Non. Hem. Staph.

B.

B. Coli

B. Coli

No growth

Non-Hemoly. Swept.

Proteus

neg.

Coli

Coli

No

organgrowth

Yeast isms

No growth

Diphtheroid! B. Coli

B.

B.

Diphthcroid! Staph.

c ram rods.

,,,.,.....

B. Pyocyane”s

No growth

No growth

B.

Strep.

Diphtheroid

Strep.

Strep

-

3

One

One

One

One

One

.-_

One

7Dnc

; One

; -stage

drainage

stage

stage

stage

stage

stage

stage

stage

drainage

drainage

stage

stage

stage

stage

stage

drainage

w dramage

drainage

drainage

drainage

Stagedrainage

stage

stage

drainage

dramage

drainage

drainage

drainage

drainage

drainage

drainage

stagedrainage

(Redrainage) One stage

-_ One

Two

7One

._

One

One

One

One

One

stage

Drain. interlobar empye”lZl

s One

-.

First stage only ol two stage drainage one stage drainage

-

I

I

I

2

I

_ I

-

_ -

_

._ _ _ -

_

-

-

-

-

zr

39

28

54

7

31

29

56

25

zo

Zys p.0.

Died

--

60

43

32

55

26

-

_

__ __

_

3

_

_

_

_

_

.

_

-

-

-

_ -

_ -

_ -

_ -

_

-

F

-

_ -

_ -

-

chemotherapy. L” excellent

pulmonary following Died s/40 hemor-

multi le in every lo g e.

SF;;“,$as I

.

bronchial

Has bronchiecrasis. Fistula still open.

Asymptomatic.

Asymptomatic. Working.

Extensive cavities

Bronchial Present

Asymptomatic. Working.

Working.

I iistula

Diabetic.

No symptoms from abscess. Has advanced pneumonoconiosis.

Transferred to Psycopathic Hospital after 1st operation. Tube removed. Abscess recurred. Redrained. Still has fist&.

Now health.

Asymptomatic. Working.

Had no symptpms operatmn. ;~aeyebral

Symptoms recurred following first operation. Redrained. Now and asymptomatic working.

dis?pfollowing drainage of lower lobe abscess. Upper reaplobe process peared. Drained. Now asymptomatic.

UpP,Paeabscess

Following 1st operation had recurrence of symptoms and abscess in lower lobe reappeared. Following 2nd drainage had uneventful co”valescence. Now asymptomatic and working.

92

American Journal of Surgrry

Betts-PuImonary

sions. He consuIted his physician who had a chest x-ray taken. (Fig. 6~.) The x-ray interpretation was tubercuIosis. ApproximateIy one

Abscess His past history revealed no pertinent information. The only previous ihness was a gonorrhea1 infection at twenty years of age.

FIG. 6. Case 21. Postero-anterior x-rays of the chest showing rapid progress of an initiaIly favorable lesion. A, August 29, 1940; B, September 6, 1940; c, September 25, 1940; D, September 27, 1940. Note the presence of an oId tuberculous process in both apices. Due to this finding, a diagnosis of tuberculosis was made and valuable time was lost.

week later the patient entered a tubercuIosis sanatorium. X-rays taken on admission there showed an extension of the Iesion. (Fig. 6~.) Repeated sputum examinations for tubercIe bacihi were negative. Bronchoscopic aspiration was carried out twice with sIight temporary improvement. The course in the sanatorium was progressiveIy downhih, the patient having a high sustained temperature, profuse prostration, copious expectoration and persistent pain in the chest. When seen in consuItation, immediate surgica1 drainage was advised. This advice was not accepted until two weeks Iater.

There had been no known contact with tubercuIosis. The patient had been married ten years. There were three chiIdren Iiving and weI1. PhysicaI examination reveaIed a markedIy dyspneic, emaciated, moderateIy cyanotic man, sitting up in bed in obvious respiratory distress. Significant abnormal hndings were Iimited to the chest. There was duIIness and diminished breath sounds over the lower two-thirds of the Ieft chest posteriorly. RaIes were heard over the entire Ieft chest and a moderate number throughout the right chest. The heart was< within norma Iimits and the sounds were of

NEW

SERIES

VOL.

LIV.

No.

I

Betts-Pulmonary

good quality. The brood pressure was mm. of mercury. A urinaIysis was essentialIy negative for a very sIight trace of aIbumin. The blood count was 37,300, red bIood 4,180,ooo per c.mm. The hemogIobin was

88/50 except white count

81 per poIymorphonucIears 77 per cent, Iymphocytes I I per cent, Iarge mononucIears 8 per cent, eosinophiIes 3 per cent, basophiles I per cent. There was moderate anisocytosis. Roentgenographic examination (Fig. 6~) showed an extensive biIatera1 invoIvement with a Iarge muItiIocuIar cavity of the Ieft upper

cent.

DifferentiaI:

Iobe. The Iower two-thirds of the Ieft chest was obliterated by a moderateIy dense homogeneous shadow. There was evidence of many smaIIer cavities throughout the upper two-thirds of the right lung. Intensive sulfanilamide therapy was started. AIthough it was thought that the outIook was practicaIIy hopeIess drainage of the Iarge abscess in the Ieft upper Iobe was decided upon. The preoperative temperature was 102’F. and the puIse rate was 160 per minute. A one-stage cautery drainage was carried out on September 28, 1940. This was foIIowed by two indirect bIood transfusions. His course folIowing operation did not change greatly. His temperature remained quite steady at around 102’~. by rectum, and the puIse 130 to 140 beats per minute. Chemotherapy was

maintained with a suIfaniIamide bIood level ranging from 8 to IO mg. per cent. FIuids were administered parenteraIIy to maintain an intake of 3,000 to 4,000 cc. per day. BIood transfusions of 500 cc. each were given on September 29, October I, and October 4, 1940. In spite of the supportive therapy it was obvious that the patient was sIowIy faiIing but there was no dramatic change in his course unti1 the morning of the tenth postoperative day when he became temperature rose to 104’~. by comatose, rectum, and the patient expired. Postmortem examination reveaIed a heaIed biIatera1 apica tubercuIous process. The Iung abscess of the Ieft upper Iobe which had been drained was found to invoIve approximately one-half of the upper Iobe. The remainder of the Ieft Iung was described as “invoIved by a massive destructive process.” One IO cm. abscess and many smaIIer abscesses were found in the right Iung. A very smaI1 abscess was present around the appendicea1 stump.

Abscess

American Journal of Surgery

93

How we11 this case iIIustrates the rapid progress such a process may make! The issue was confused in this particuIar instance because of the presence of an oId tubercuIous process at the apices. The deveIopment of the Iung abscess in the upper Iobe made it seem a11 the more IikeIy that it was tubercuIous. This assumption accounted for part of the Ioss of time in the application of proper therapy. Only within the first ten days after onset of symptoms couId this patient be classed as at all hopefu1. By the time of admission to the sanatorium, the prognosis was very grave, again iIIustrative of the faIIacy of temporizing with a Iesion so potentiaIIy dangerous. In the Iight of other cases it seems quite probable that had the original abscess been drained when it was first detected, the fata issue would have been averted. CASE 9. Mr. T. C., a forty-three year oId, married, ItaIian cIerk was admitted to the New EngIand Deaconess HospitaI on August 24, 1939, with a chief compIaint of cough, expectoration, and pain in the right chest of four weeks’ duration. On August 16, 1939, the patient developed symptoms of acute appendicitis. At operation the folIowing morning a ruptured appendix was found. This was removed and a drain inserted. A right inguina1 hernia was repaired at the same time. The patient had a stormy time postoperativeIy and ten days after operation began to compIain of pain in the Ieft chest. A cough deveIoped and the temperature became more eIevated. It was thought at first that he had a puImonary emboIus. Soon the patient began to raise large amounts of fouI-smeIIing materia1. A feca1 fistuIa deveIoped at the site of the appendectomy. SuIfapyridine was given without benefit. RoentgenoIogicaI examination of the chest reveaIed a Iarge Iung abscess in the Ieft Iower Iobe. Thoracic surgical consuItation was requested and the patient was transferred the folIowing day to the New England Deaconess HospitaI. PhysicaI examination reveaIed a very ill man sitting upright in bed, breathing with effort, coughing frequently and raising foul sputum. Many raIes couId be heard throughout the posterior aspect of the Ieft chest. Amphoric

94

American Journal of Surgery

Betts-Pulmonary

brea lth sounds were audible over the seventh and eighth ribs posteriorly. A profusely draining :Gnus was found in the right Iower quadrant

Abscess

OCIOREI<, 1

The patient was followed at weekly interva AS. For some time it was thought that it wouId be necessary to do a plastic operation in order to

FIG. 7. Case 9. Postero-anterior x-rays of chest. A, August 24, 1939. Note Iarge multiIocuIar abscess with surrounding pneumonitis in left lower Iobe. B, August 23, 1940. Lesion has now cleared completeIy, following surgicat drainage, except for slight pulmonary fibrosis.

of the abdomen. A right inguina1 herniorrhaphy scar was we11 heaIed. The remainder of the examination was not significant. Urine examination was norma except for 14 to I 8 white bIood ceIIs per high power fieId. The white bIood count was 2 I ,700; red blood count, 3,580,ooo per c.mm. The hemogIobin was 50 per cent. DifferentiaI: poIymorphonucIears 92 per cent, Iymphocytes 3 per cent, eosinophiIes I per cent, young poIys 4 per cent. Moderate achromia of the red blood ceIIs was noted. X-ray examination of the chest (Fig. 7~) reveaIed a large multiIocuIar abscess in the Ieft Iower lobe with surrounding pneumonitis. The patient’s condition was desperate, temperature IOI’F., pulse rate 146 per minute. A bIood transfusion of 500 cc. was given as soon as possibIe after admission, and Iater that day a one-stage cautery drainage of the Iung abscess of the Ieft lower lobe was carried out. The patient’s improvement foIIowing operation was dramatic. The temperature returned to norma by the end of the first week. The puIse rate gradually dropped to an average of IOO within the same time. The feca1 fistula cIosed spontaneousIy. The patient was able to be out of bed thirty days after operation and was discharged seven days Iater. The Iarge defect of the Ieft Iower Iobe graduaIIy fiIIed in and shortIy before discharge a drainage tube was inserted to keep the skin from cIosing over.

cIose the bronchia fistula. However, the fistuIa heaIed spontaneousIy and the tube was removed on January 2, 1940, three and one-haIf months after discharge from the hospital. Since that time he has been entireIy without symptoms. now one and one-half years. He has returned to fuI1 time work and is in exceIIent heaIth. (Fig. 7~.)

The postoperative response of this patient presents a dramatic iIIustration of the marked improvement that may be experienced by an acuteIy III, toxic patient as soon as the abscess is decompressed and the patient is freed of persistent coughing and raising. AIthough this particuIar case was complicated due to an extensive pulmonary process with surrounding pneumonitis, a feca1 fistuIa, and marked debilitation by the Iong septic process, the period of hospitaIization folIowing operation was not excessive and an exceIIent resuIt was obtained. Judging from the patient’s preoperative course, further temporizing wouId have been fataI. CASE 22. Mr. L. C., a thirty-nine year old, married, American, carpenter was admitted to the New EngIand Deaconess Hospital December 3, 1940, with a chief compIaint of cough and expectoration of six weeks’ duration.

NEW SERIES VOL. LIV, No. r

Betts-PuImonary

-I‘he patient stated that in March, 1939, he was; in another hospital for eight days because of crough and the raising of profuse, foul-smeh-

Abscess

American Journal of Surgery

95

ousIy, a fiIm on November 7, 1940, (Pig. 8~) was said to have been the first one to show any abnormality. The cough was quite distressing

FIG. 8. Case 22. A, postero-anterior x-ray of chest. November 7, 1940, showing some infiltration of mediastinal seement of left nnoer lobe. The onlv” comolaint at that time was severe chest pain. B and c, postero-anterior and left latera x-rays of chest approximately one month later, December 4, 1940. Patient now has a large lung abscess with marked cough and profuse expectoration. D, February IO, 1941. Lesion has now cleared completelv following surgical drainage. Note lipiodal still in intercostal tissue above resected rib. A

sputum. A diagnosis of Iung abscess was said to have been made at that time on x-ray and clinica evidence. Upon discharge from the hospita1 he remained home for four months on a modified rest program. He then returned to work. He felt we11 unti1 the Iatter part of October, 1940, when he suddenly feIt severe pain in the Ieft side of the chest. After a two weeks’ period at home he was transferred to the Essex County TubercuIosis Sanatorium for observation. AIthough numerous x-rays had been taken previing

.

and he raised from two to three ounces of fou1 sputum per day. SurgicaI drainage was advised. His past history was negative except for the episode recorded in the present iIIness. The family and marita1 histories were noncontributory. PhysicaI examination reveared the patient to be a we11 deveIoped and we11 nourished man in no particuIar distress. There was moderate ora sepsis. The chest was symmetrica and expansion was fuI1 and equa1. There was duIIness to percussion over the upper part of the Ieft

96

American Journal of Surgery

Betts-Pulmonary

posterior chest. Harsh breath sounds were noted together with moist raIes in this same area. The remainder of the chest showed nothing abnorma1. The abdomen showed a we11 heaIed Iower quadrant scar. Extremities were negative. Laboratory examination reveaIed nothing abnorma1 in the urine. The white bIood count was 28,200; red bIood count, 4,650,000 per c. mm. and the hemogIobin was 87 per cent. Differential: poIymorphonucIears 87 per cent, Iymphocytes 5 per cent, Iarge mononucIears 4 per cent, eosinophiIes 4 per cent, basophiIes r per cent. RoentgenoIogicaI examination of the chest (Fig. 8~ and c) reveaIed an abscess in the Iower part of the left upper Iobe. A one-stage cautery drainage of the Iung abscess was carried out December 4, 1940. Postoperative convaIescence was entireIy uneventfu1, the temperature never going above IOOOF.The pack was first changed four days after operation and every other day thereafter unti1 the seventeenth postoperative day when a smaI1 rubber tube was inserted in pIace of the pack. The patient was aIIowed out of bed fifteen days after operation and was discharged on the twentieth postoperative day. FolIowing discharge from the hospital, he was foIlowed at weekly intervaIs and on February I, 1941, the fistuIa was found to be cIosed and the tube was therefore removed. The chest waI1 healed promptly. When Iast seen on March 24, I 941, the patient had no complaints and an x-ray (Fig. SD) showed complete cIearing of the puImonary process. He was given permission to resume normal activities. One can specuIate a great deaI as to the Iength of time the Iesion had been present. It is entireIy possibIe that the recent abscess was the same Iesion that was present in March, 1939. The re-activation of an abscess after apparent spontaneous heaIing has been a rather frequent occurrence. The rapid recovery made in this case again demonstrates that a smooth convaIescence can be expected foIIowing drainage of an uncompIicated singIe abscess. Recurrence is rare foIIowing externa1 drainage. CASE 23. Miss V. G., a thirty year oId, s;ngIe woman, was admitted to the New

Abscess EngIand Deaconess HospitaI on January 30, 1941, with a chief complaint of cough and temperature of two weeks’ duration. Two weeks previousIy the patient had suddenIy deveIoped a high temperature, cough, and pain in the right chest. She was admitted to the Joseph H. Pratt Diagnostic HospitaI where a diagnosis of right upper Iobar pneumonia was made. A chest x-ray reveaIed a shadow in the right upper Iobe consistent with Iobar pneumonia. Intensive chemotherapy was given. Her temperature continued to range from IOO to 102’F., puIse rate IOO to I 20. After thoracic surgica1 consulta-

tion, surgica1 drainage was advised and the patient was transferred to the New EngIand Deaconess HospitaI. The patient had been a quite severe asthmatic since August, 1938. She was known to be sensitive to dust, Iettuce and spinach. On intensive alIergic therapy, however, she had been abIe to contro1 her symptoms quite well. Two years previousIy a splenectomy had been performed for a ruptured spIeen foIIowing an automobiIe accident. One year previously an ectopic tuba1 pregnancy was removed. PhysicaI examination reveaIed a thirty year oId white woman sitting upright in bed in obvious respiratory distress. Respiratory wheezing was marked. Examination of the head and neck showed no abnormaIity except for very poor teeth. Percussion of the chest reveaIed duIlness and diminished breath sounds over the upper part of the right chest posteriorIy and in the right axiIIa. No raIes were audibIe. TactiIe and vocal fremitus were sIightIy increased. Wheezing and proIonged expiratory sonorous rales were heard throughout both chests. The heart appeared to be of normal size and without murmurs. The bIood pressure was 120/70 mm. of mercury. AbdominaI examination was negative except for Ieft upper quadrant and Iow midhne well heaIed scars. The remainder of the physica examination showed no abnormality. The temperature was IO~‘F.; pulse 140; respirations 30.

A urinaIysis showed no marked abnormahty except a sIight trace of albumin and an occasiona1 fine granuIar cast. The white bIood count was 19,400; red bIood count 4,600,000; hemogIobin 70 per cent. The differentia1 count showed 63 per cent poIymorphonucIears, 15 per cent bands, 7 per cent Iymphocytes, IO per cent monocytes, and 5 per cent eosinophiIes. Serological examinations cuIture was sterile.

were negative.

One bIood

NEW SERIES

VOL. LIV,

No.

I

Betts-PuImonary

Roentgenographic examination of the chest (Fig. 9~ and B) revealed evidence of consolidation of the posterior portion of the right upper

Abscess

American

Journal

of Surgery

97

occasions since that time. The wound is completeIy heaIed, and the Iast x-ray (Fig. 9c) shows complete clearing of the Iesion.

FIG. g. Case 23. A and B, postero-anterior

and right lateral x-rays on January zg, 1941, showing involvement of lower part of right upper lobe. No evidence of cavitation. c, posterior-anterior x-ray April 18, 1941. Note compIete ctearing of process following surgica1 drainage.

lobe. The shadow was Iimited below by the interIobar fissure, but the upper borderline was indistinct. No definite cavity was visibIe. Although definite evidence of a Iung abscesslby x-ray was not present and the patient had practically no sputum, a diagnosis of Iung abscess or intedobar empyema was made and operation advised. (the day of admission On January 30, 1941, to the Deaconess HospitaI), under IocaI anesthesia, the posterior aspect of the right upper lobe was expIored after resecting a portion of the fifth rib posteriorIy. A muItiIocuIar abscess was entered, the cavities being tiIIed with very thick, cheesy, yeIIowish pus. These abscesses were broken down and the space packed with gauze after appIication of suIfathiazoIe powder. BacterioIogicaI examination of the material from the abscess revealed steriIe cultures both aerobicaIIy and anaerobicaIIy, aIthough Grampositive cocci were found in cIumps upon direct smear. The patient’s postoperative convaIescence was satisfactory. AIthough the temperature rose to 103.5’~. the day of operation, it returned to normaI quite rapidly and her genera1 condition improved markedly. The patient was discharged from the hospita1 twenty-five days foIIowing drainage of the abscess. She was foIIowed at weekIy intervaIs. A smaI1 tube which had been in pIace in the sinus tract before she Ieft the hospita1 was withdrawn as the sinus tract cIosed in. The tube was removed on May 16, rgq.1. She has been seen on two

In this case a persistent area of infiItration by x-ray and continued signs of sepsis folIowing an attack of pneumonia suggested pulmonary suppuration. Destruction of puImonary parenchyma did not seem to be as extensive as that usuaIIy caused by anaerobic organisms. No area of excavation was present roentgenographicaIIy but at operation many smaI1 connecting pockets were found. It is better to expose such Iesions surgicaIIy than to wait a proIonged period of time for definite evidence of cavitation by x-ray. SUMMARY

AND

CONCLUSIONS

EarIy drainage of Iung abscess has yieIded a Iow mortaIity rate and a high cure rate in our experience. A series of twenty-five consecutive cases of pulmonary abscess treated by surgical drainage has been presented. There was one operative death. InhaIation of materia1 from the upper respiratory passages appeared to be the causative factor in the vast majority of cases. Symptoms had been present from one week to one year and two months before operation. Five patients had muItipie abscesses, four of which were in more than one Iobe. In a11 cases surgica1 drainage was provided as soon after admission to our service

98

Anlerican.Iournalof Surgcr,y

Betts-PuImonary

as diagnostic and localizing studies couId be compIeted. CriticalIy iI patients were treated as surgica1 emergencies. EarIy surgica1 drainage protects the patient from the danger of bronchiogenic spread, muItipIe abscess formation and extensive irreparabIe puImonary damage. PuImonary abscess shouId be considered a surgical disease from its onset. Every effort shouId be made to estabIish the diagnosis, Iocalize the Iesion, and provide externa1 drainage without deIay.

Abscess

7.

8.

9. IO.

II.

REFERENCES I. SWEET, RICHARD H. Lung abscess. Surg., Gynec. Ed Obst., 70: 1011, 1940. 2. CC.TLER, E. C. and GROSS, R. C. Non-tuberculous abscess of the Iung. J. Tboracic Surg., 6: 125, 1936. 3. BRUNN, H. Lung abscess. J. A. M. A., 103: rggg, ‘934. 4. NEUHOF, H. and TOUROFF, A. S. W. Acute putrid abscess of the lung; principles of operative treatment. Surg., Gynec. ti Obst., 63: 353, 1936. 5. NEUHOF, H. and TOUROFF, A. S. W. Acute putrid abscess of the lung. II An analysis of forty-five consecutive cases. Surg., Gynec. CYObst., 66: 836,

1938.

6. NEUHOF, H., TOUROFF, A. S. W. ~~~AUFSES, A. H. The surgical treatment by drainage of subacute

12.

13.

r4.

15. 16.

Ocronl:R,lQ$l

and chronic putrid abscess of the lung. Ann. Surg., 113: 209, 1941. OV~RHOLT, R. H., and RU.\IEL,W. R. Factors in the reduction of mortality from puImonary abscess. New England J. M., 224: 441, 1941. JACKSON, C. L. and JUDD, A. R. The role of bronchoscopy in the treatment of pulmonary abscess. J. Thoracic Surg., IO: 179, 1940. STERN, L. Putrid abscess of the Iung foIIowing denta operations. J. Thoracic Surg., 4: 547, 1935. STERN, L. Etiological factors in the pathogenesis of putrid abscess of the lung. J. Tboracic Surg., 6: 202, 1936. MATHES, M. E., HOLMAN, EMILE, and REICHERT, F. L. A studv of the bronchiat oulmonarv and Iymphatic cir&Iations of the Iung under vkious pathological conditions experimentaIIy produced. J. Thoracic Surg., I : 339, 1932. GLASS, AMEIL. The bronchopulmonary segment with special reference to putrid lung abscess. Am. J. Roentgenol. CYRad. Tberapy, 31: 328, 1934. KING, D. S. and LORD, F. T. Certain aspects of puImonary abscess from anaIysis of two hundred and ten cases. Ann. Int. Med., 8: 468, 1934. ROSENBLATT, M. B. Putrid lung abscess: pathogenesis, prognosis, and treatment. J. Tboracic Surg., g: 294. 1940. ALLEN, C. I. and BLACKMAN, J. F. Treatment of lung abscess. J. Tboracic Surg., 6: 156, 1936. RIVES, J. D., MAJOR, R. C. and ROMANO,S. A. Lung abscess: an anaIysis of the causes of death in one hundred consecutive fatal cases. Ann. Surg., 107: 753, 1938.