The

BRITISH JOURNAL
OF RADIOLOGY
F O U N D E D

JUNE 1944

VOL. XVII

THE

1896

DIAGNOSIS AND

No. 198

TREATMENT OF LUNG ABSCESS

SYMPOSIUM*

By T .

SELLORS, D.M., M.Ch. (Oxon), F . R . C . S .

Surgeon, Thoracic Unit (E.M.S.), Harefield,
Surgeon to the London Chest Hospital

HOLMES

OST classifications of lung abscesses are unM

satisfactory and confusing. When the term is
mentioned only one or two varieties generally come
to mind, but if the literal definition of an abscess of
the lung is adhered to, a much wider field would
have to be considered. However, from the surgeon's
point of view the only type that has to be considered
in detail is the single pyogenic abscess which gives a
fairly constant clinical picture. The toxic and fcetid
character of this abscess has led to it being given the
name of the solitary putrid abscess of lung. The
immediate concern of surgery with this form should
not be taken as implying that surgery has no place
in the treatment of other varieties of abscess.
Individual cases and pleural complications may
require drainage, but apart from the putrid abscess,
surgery is not often required.
When considering the aetiology of putrid lung
abscesses the contemporary weight of evidence
seems to favour an inhalation or bronchial embolic
causation rather than a blood borne infection. If
this is so, there are two essential factorslodging of
foreign infected material in the terminal air-tubes
and failure of the normal expulsion mechanism to
deal with this alien matter. The defence mechanism
of the air passages is a complicated one consisting of
a continuous movement of active cilia and the
bronchial musculature from depths to surface, and
the powerful blast of the cough reflex. Many circumstances may transitorily or permanently interfere with this protection and one has only to
instance anaesthesia, heavy sedatives, persistent
inflammatory changes, to realise the numerous
occasions on which the air-tubes are "off-guard".
The inhaled or aspirated material may on occasions consist of foreign bodies of which the pea-nut
* DiscussionFaculty of Radiologists, February 19, 1944.

or an extracted tooth is the traditional example, but

these relatively large objects tend to produce
atelectasis with resultant bronchiectasis rather than
a conventional abscess. Microscopic fragments of
infected matter are far more common causes, and if
the bacterial flora of teeth and lung abscesses are
compared the view that most of these latter originate
from dirty tooth sockets and the naso-pharynx gains
considerable support.
The infected plug or embolus is aspirated into a
small terminal air-tube, which it blocks. Atelectasis
distal to the obstruction is probably the initial
process to be followed quite quickly by infection
which ultimately spreads to surrounding tissue.
Centrally the usual pathological processes of central
suppuration, thrombosis, sequestration of tissue
form the breaking down centre of the abscess which
becomes walled off by consolidated lung and
fibrous tissue barriers (Fig. 5). The spherical form
of the abscess depends on the usual features that
maintain this shape in the elastic and continuously
moving lung.
Several minor points in connection with the
pathological anatomy of abscesses demand attention.
The situation of the average abscess is peripheral
since a small air-tube is usually the original site of
the plug, but though it lies close to the surface
rupture into the pleural sac is uncommon. Pleural
adhesions are always found immediately over the
abscess and a narrow zone of viable lung tissue lies
between pleura and the abscess cavity. Barrett has
suggested that this absence of necrosis depends on
the presence of a plexus of veins that lie in the subpleural plane.
The bronchus that was originally obstructed
becomes patent as the plug liquefies and leaves an
opening between abscess cavity and the air-tubes.
Now if this opening is of adequate size the contents

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T. Holmes Sellors

FIG.

A.

i/r^^o.
MIT

FIG.

FIG.

B.

166

C.

JUNE

1944

The Diagnosis and Treatment of Lung Abscess

of the abscess will be extruded and coughed up as
foul sputum, and on some occasions this can and
does occur. Also it is a clear basis for treatment by
postural drainage methods. Unfortunately the opening, already small, becomes further narrowed by
oedema, granulation tissue and so on, so that distension rather than evacuation occurs. The drainage
of pus into the bronchi may lead to aspiration into
dependent tubes"spill-over"if cough is not
effective.
This point leads to two definite observations in
relation to diagnosis and treatment. Bronchoscopy
may remove loose pus in the air-tubes, but no suction tube can reach deep enough down the bronchial
tree to touch the abscess opening, much less enter it.
Bronchography is also contra-indicated in most
cases in the early stages. The oil is too heavy and
thick to pass the bronchial opening, and its residuum
will obstruct the radiological assessment of the
abscess progress.
It is often supposed that lung abscesses are most
frequently found in the base of the lung, but in
actual fact the most common sites are the posterior
part of the upper lobe and the apex of the lower
lobe. The explanation for these apparently unexpected situations may be found in a study of the
anatomy of the bronchial tree (Figs. A, B, and C).
A brief description of the distribution of the sublobar bronchi is valuable in this connection. The
upper lobe bronchus gives off 3 or 4 stems which
may be designated as anterior and posterior apical,
pectoral and scapular or sub-apical. The important
tube in connection with abscess formation is, as
Brock has pointed out, the scapular or sub-apical.
This gives off one branch which runs directly backwards to "supply" the lowest and most dorsal part
of the upper lobe, and another which turns into the
axilla (Fig. D). The pectoral bronchus supplies the
anterior part of the upper lobe and gives off an axillary branch whose zone of supply is contiguous with
the axillary of the scapular. Now it is important to
recall the position that the patient will adopt in sleep
or under anaesthesia, with the individual lying down
or on the side. The scapular or axillary branches will
be the dependent tubes, and it is here that many
abscesses are found.
The middle lobe or lingula are supplied by tubes
that run forwards and downwards, and if they are to
be dependent, the patient would have to be lying
3n the face. Morriston Davies has recently des:ribed the evolution of abscesses in this site as the
result of inhalation of marine oil by sailors swimming
n the sea. The lower lobe basal bronchi are the
dependent air-tubes with the patient in the erect
)osture, but it must be remembered that this posiion is one that favours the most effective cough
iffort and is not one adopted by an unconscious
?atient. But in the lower lobe there is another
mportant branch, the first dorsal, which supplies
:he apex of the lobe. This runs directly backwards

off the main bronchus stem. It seems highly probable that posture will thus account for the location
of many lung abscesses, with the scapular (Fig. D)
branch of the upper lobe and apex of lower lobe as
the most common sites.

FIG.

D.

When it comes to any discussion of treatment of

lung abscess, the story is not a particularly happy
one. Conventionally it is taught that any abscess
should be given the benefit of conservative or
postural treatment for the first 6 to 8 weeks of its
course. Certainly a proportion of lung abscesses
will heal on this basis and the figure of |J is given
as the proportion that may attain spontaneous cure.
If, however, the abscess increases in size or the
general condition is deteriorating, urgent surgery in
the form of drainage before the end of this arbitrary
period is essential. Drainage is also held to be indicated at the end of the period if the abscess is not
showing definite signs of regression. The sad story
of many lung abscesses is that they are not even
given any opportunity of surgical drainage until the
condition has passed into hopeless chronicity with
secondary bronchiectasis, "gitterlunge" formation
and liability to exacerbations (Fig. 12). Surgical
drainage can only give incomplete benefit if this
stage is reached.
The mortality is a real index of the severity of the
condition. Figures suggest that the death rate lies
between 25 and 40 per cent., an alarming high figure.
On the other hand there has been a definite ray of
hope in results published from Mount Sinai
Hospital at New York. The basis of the attack by
Neuhof and his colleagues on the problem consists
of really early drainage of practically all abscesses.
Technically the aim is to do a one-stage drainage
while the adhesions that are forming are really sticky
and glue-like. In the later stages these adhesions
become more string-like, and there is a distinct
chance that the pleural cavity will be opened. This
latter eventuality with its associated dangers has to
date dominated the technical side of abscess drainage and has led to the frequent use of a two-stage
method, the first stage being to occlude the pleural

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T. Holmes Sellors
cavity by use of a firm extrapleural pack or "plombe".
Then after an interval of 10 to 14 days the actual
drainage is performed, by removing the roof off the
cavity with diathermy. I have been in the habit
recently of doing a preliminary stage at the earliest
moment, and if the adhesions are firm enough, to
proceed to drain the abscess then and there. If the
pleura appears free an iodine pack is inserted and
the wound closed for a fortnight. It is poor practice
to wait until drainage has become inevitable and
then find that the actual evacuation of pus has to be
postponed for a damaging period of 1 to 2 weeks.
Even when an abscess has been apparently satisfactorily drained the dangers of haemorrhage and
cerebral embolism are very real considerations.
It will be a considerable time before the surgeon
can see all acute abscesses in the early stage, as the
period of pulmonary destruction seems to be a
jealously guarded medical privilege. Generally the
case is only referred to the surgeon when every hope
of spontaneous cure has lapsed and the condition
has become definitely chronic. The solution is
clearly to let the surgeon see all cases as soon as they
are recognised and to join in the appraisal of the
individual merits of each case as to the performance
of active or conservative treatment. There is no
doubt that early drainage promises far better results
than other methods; even if later successful drainage is
established, the chances of a persistent epithelialised
cavity and secondary bronchiectasis are considerable. The condition can then only be cured by
pulmonary excision in the form of a technically very
difficult lobectomy. With definite chronic abscesses
the question of their removal as opposed to drainage
may be considered. This, however, is not an easy
decision to make, and from experience I would
never advocate lobectomy unless the cavity has been
first adequately drained either through a bronchus
or externally.
The importance of radiology in lung abscess is
unquestioned and there are several aspects to be
considered. In the earliest stage of the condition the
radiological shadow may constitute diagnostic difficulties, though these are usually solved when the
clinical picture is also taken into account (Fig. 7). As
soon as any sign of breaking down is recognised the
question of localisation is of paramount importance,
and here the absolute necessity for lateral films will
be recognised. Even with an abscess situated deep
to the scapulathe area of visual and mental
obscurityan accurate assessment of the cavity's
position should be made; if early drainage is contemplated it is well worth spending a considerable
time, subject to the patient's physical condition, in
working out the prospected approach. The position
of the scapula can be altered by moving the arm, so
that the surgical attack can be made direct on to the
adherent area over the cavity (Fig. E). It must be
mentioned that any suspicion of fluid over the
affected area should not constitute an indication for

the use of the aspirating needle. Needling over a

suspected abscess is a highly dangerous undertaking.
It has been found desirable for radiologist and
surgeon to screen the patient together prior to early
operation, so that the position of the arm and scapula
prior to operation can be rehearsed and the centre of
the cavity be accurately sited. The "spot" method of
injecting a few minims of opaque oil and dye close
to the pleura and then checking the position of this
marker radiologically in relation to the abscess, can
be used with advantage in some cases.

FIG.

E.

The progress and conservation treatment of an

abscess can derive considerable help from radiology.
Once the cavity has been located segmentally, the
position of the patient can be determined so that the
affected bronchus is dependent. The presence or
persistence of a fluid level is a certain indication of
the failure or impracticability of intra-bronchial
drainage. During the first two to four weeks frequent radiographs are advisable to control the course
of the condition. Improvement in the general condition associated with an early cavity and a clearing
periphery suggests that spontaneous resolution may
be taking place. A fluid level with an enlarging
cavity and increasing pneumonitis is an indication
for active intervention. Perhaps actual sloughs
which could never be evacuated through the draining bronchus may be visualised.
If two-stage drainage is practised it is useful to
place a metallic marker (a length of fuse wire in
rubber tubing) in the bed of the resected rib among
the packing used to promote adhesions (Figs. 13 and
14). In this way the accuracy of the approach can be
checked by antero-posterior and lateral films before
the second stage. During drainage the use of barium
loaded tubing may be a wise measure since it is not
always easy to visualise tubing in the region of the
scapula, and the movements of the arm frequently
dislodge the tube from the cavity and leave it lying in
the muscle or subcutaneous planes. Control of healing which cannot be visualised directly or by ordinary
radiographs may be helped by filling the cavity
loosely with gauze soaked in radio-opaque oil
(neo-hydriol). Filling of the healing cavity with oil

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The Diagnosis and Treatment of Lung Abscess

is almost certain to lead to some escape of the oil into
the bronchial tree through one or more of the
inevitable fistulae. When the cavity has healed it is
advisable to perform bronchography of the affected
lobe so that the condition of the bronchi can be
defined; the probability of some bronchiectasis
adjacent to the healed abscess has already been
mentioned (Fig. 15).
Persistence of a fistula should lead to a careful
re-assessment of the whole problem; the cavity may

have been chronic at the outset and the walls become lined with epithelium from skin or bronchus,
but the real consideration is really whether the condition is simply a pyogenic infection, or if there is a
malignant, congenital or tuberculous basis. Admittedly this is more of a pathological than radiological problem, but a review of every circumstance
in the course of the case is not one of the least
benefits towards our understanding and control of a
formidable problem.

L. G. BLAIR, M . R . C . S . , L . R . C . P . , D . M . R . E .
Radiologist, Thoracic Unit (E.M.S.), Harefield
Y definition an abscess is a localised collection of
B
pus in a cavity, formed by the disintegration
of tissues. It is, therefore, obvious that a lung
abscess in the broad sense of the term can include a
variety of conditions. Presumably, however, in this
discussion we are concerned with the abscess of lung
caused by pyogenic organisms, and therefore, as
radiologists we are primarily concerned with the

FIG. 1.
Early acute pyogenic lung
abscess, right apex.

FIG. 2.
Suppurative pneumonitis,
right apex.

down quickly into a central cavity, and remains

localised throughout (Fig. 1), except that occasionally
a tip-over spread may occur, and a fresh localised
abscess form in another area of the lung.
In the next group (described by Scadding (1935)
as chronic (suppurative) pneumonia), there is an
extensive area of consolidation which may or may
not be confined to one lobe, and which tends to

FIG. 3.
Same case eight weeks
later. Spread to mid zone,
and a fresh cavity.

differential diagnosis of the shadows which may be

given by this type of lesion.
Cases of pulmonary suppuration can be separated
into four fairly clear-cut groups according to their
radiological appearances.
The first group, for which the term acute pyogenic lung abscess should be reserved, shows a
lesion which starts in a localised area of lung, breaks

FIG. 4.
Same case eight weeks
later. Clearing in upper
zone. Fresh cavity in the
mid zone.

break down, first in one area, and then in another,

and sometimes showing healing in the original areas,
as fresh areas of lung are involved apparently by
direct spread (Figs. 2, 3, and 4). The predominant
picture is one of extensive consolidation with areas, of
softening. Not only is there a radiological difference
in these two groups, but there tends to be a difference
in onset, in symptomatology, and in prognosis, and

169