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Setptember I948 ELLIOTT and YOUNG: Treatment of Acute Empvema
Thoracis 475
For chronic fissure in ano, surgical excision andsuture has been
practised with surprisingly goodresults. A stay suture is inserted
at the proximaland distal extremities of the fissure which is
madeprominent by tension on each stay. The fissure isthen easily
excised with the subjacent portion ofthe subcutaneous external
sphincter. Two or threefigure-of-eight sutures of fine nylon are
placed,one of which approximates the cut ends of thesphincter. A
layer of gauze is wrapped round asmall soft rubber tube and the
sutures are tiedlightly over it. The bowels are confined for
sixdays and the dressing remains clean until thesixth day when the
sutures are removed and anolive oil enema is given. The sutures are
easilyremoved by cutting over the dressing. Liquid
paraffin by mouth and local Vaseline beforedefaecation are used
for two subsequent weeks, andit is interesting to note that the
writer has not seenfistula formation after this procedure. There
isalso an economy in hospital days as compared withwounds allowed
to heal by second intention.Time lost from work in the treatment of
a
minor disability, although of secondary signifi-cance to
successful treatment, is nevertheless ofmajor importance to the
individual and to thecommunity. The aim of the modificatioins
intechnique and management which have beendescribed, has been to
achieve cure or comfort inthe shortest possible time. The guiding
principlehas been close attention to the smaller clinical
andtechnical details.
TREATMENT OF ACUTE EMPYEMA THORACISWITH INTRAMUSCULAR AND
INTRAPLEURAL
PENICILLINBy W. A. ELLIOTT, M.D. (Camb.), M.R.C.P.
Trainee Specialist Physicianand
> B. A. YOUNG, M.D.(Lond.), M.R.C.P.Physician Superintendent,
St Alfege's Hospital, Greenwich
This paper is based on a series of 22 cases ofacute empyema
admitted to this hospital betweenMarch, 1945, and August, 1947. The
underlyingdisease was lobar pneumonia in i8 cases,
broncho-pneumonia in one case, lung abscess in one caseand neoplasm
in two cases. The duration ofsymptoms before admission to hospital
variedfrom three days to six weeks. (The onset ofsymptoms is
reckoned from the first day on whichthe patient felt ill, as the
date of onset of theempyema cannot be accurately determined.)While
acute toxaemic symptoms were present,
the patients were given intramuscular penicillinin doses
sufficient to maintain a continuous bac-teriostatic concentration
of the antibiotic in theblood-stream (usually 6o,ooo units
four-hourly).In addition, the pleural cavity was aspirated
ascompletely as possible through a wide bore needleon alternate
days and intrapleural penicillin(usually 250,000 units) was
injected. (Smallerdoses were given in some of the earlier cases
inthe series.) The fluid withdrawn was culturedand the sensitivity
to penicillin of the organismsgrown, was estimated.' Breathing
exercises werestarted as early as possible in all cases.
This method of treatment gave good results in14 of the pneumonic
cases and in the lung abscesscase. Details are given in the table
below. Theaverage time spent in hospital in these cases was52 days;
the average time after this for the chestradiographs to become
clear was five weeks.Good functional results were obtained in all
I5cases. In four other pneumonic cases, rib resectionand drainage
was carried out after a course ofintramuscular and intrapleural
penicillin. In oneof these four cases, the culture of the pus
fromthe pleural cavity grew bacterium coli which wasresistant to
penicillin. In another case, in whichthere was a large pneumococcal
empyema (61pints) on admission, a pyo-pneumothorax occurredduring
treatment. The remaining two cases whichwere treated surgically,
were early in the seriesand received relatively small doses of
penicillin;one of them having no intramuscular penicillin.In the
light of our later experience we considerthat both these cases
would probably have clearedup without operation had larger doses of
penicillinbeen given. The remaining pneumonic caseimproved
considerably with intramuscular andintrapleural penicillin and the
patient was dis-
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POST GRADUATE MEDICAL JOURNAL
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September 1948 ELLIOTT and YOUNG: Areatment of Acute Empyema
Thoracis
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POST GRADUATE MEDICAL JOURNAL
charged from hospital after 29 days, but she wasre-admitted with
acute purulent bronchitis 23 dayslater and died the same day. The
post-mortemexamination showed that the empyema hadcompletely
resolved. In the two cases in whichneoplasm was the underlying
disease (one secon-dary sarcoma of lung and the other
bronchialcarcinoma), the symptoms and signs caused bythe empyema
disappeared with treatment andthere was a considerable temporary
improvementin the general condition of the patients. One ofthem
later died from bronchial carcinoma andthe post-mortem examination
showed that theempyema had almost entirely resolved, leavingonly a
few adhesions in the pleural space.
Case RecordsFor cases successfully treated with intra-
muscular and intrapleural penicillin see pages476 and 477.
Cases treated with rib resection and drainageafter a course of
intramuscular and intrapleuralpenicillin.
Case i. Male, aged 70. Admitted to hospitalwith left lobar
penumonia; four days ill beforeadmission. Given 48 grammes
sulphamezathinewith considerable improvement, but
developedpneumococcal empyema eight days after ad-mission. Thin
pus, which rapidly thickened.Most pus removed at single aspiration
was 15 OZ.Had one injection of 6o,ooo units intrapleuralpenicillin
followed by eight injections of 20,000units intrapleural penicillin
on alternate days.No intramuscular penicillin. The pus
rapidlybecame sterile and thickened. Rib resection wasdone after
the course of intrapleural penicillin.A good functional result was
obtained, but theradiograph taken four weeks after operationshowed
some pleural thickening and slight fibrosisof lung.
Case 5. Male, aged 52. Admitted to hospitalwith right lobar
pneumonia and empyema; fourdays ill before admission. Pus from
pleuralcavity grew staphylococcus aureus. Most pusremoved at single
aspiration was I0 oz. Thinpus on admission. Treated with 24
grammessulphathiazole followed by intramuscular peni-cillin, 30,000
units four-hourly for eight days.One injection of I50,000 units
intrapleural peni-cillin and one of 6o,ooo units intrapleural
peni-cillin. The pus rapidly thickened and becamesterile. Rib
resection was then done; the patientwas afebrile three weeks after
operation. Fourweeks after operation the chest x-ray was
prac-tically clear.We consider that both these cases would
probably have cleared up without operation hadlarger doses of
penicillin been given.
Case I+.. Female, aged 33. Admitted to hos-pital with left
empyema, the pus from whichgrew B. Coli, which was resistant to
penicillin.The patient was therefore treated by rib resectionand
drainage when the pus had thickened. Sixweeks after operation the
chest x-ray was prac-tically clear and there was a good
functionalresult.
Case I5. Female, aged 35. Admitted to hos-pital with left lobar
pneumonia and pneumococcalempyema; I4 days ill before admission.
Treat-ment was started with intramuscular penicillin6o,ooo units
four-hourly and intrapleural peni-cillin, 250,000 units on
alternate days, but theempyema was very large, (6j pints pus
removedat one aspiration) and a pyo-pneumothoraxoccurred during
treatment. Rib resection anddrainage was therefore done, when the
pus hadthickened (2 weeks after admission). A fairlygood functional
result was obtained eleven weeksafter operationt, but there was
some residualpleural thickening.
Pneumonic case in which Empyema resolved, but inwhich death
occurred later from Acute PurulentBronchitis.
Case 9. Female, aged 65. Right lobar pneu-monia with ermpyema,
28 days ill before admissionto hospital. Seropurulent pleural fluid
which wassterile. Most pus removed at single aspirationwas 20 OZ.
Intramuscular penicillin, 6o,ooo unitsfour-hourly for I4 days. Four
injections of 120,000units intrapleural penicillin. Was
dischargedconvalescent after 29 days, but was readmitted tohospital
23 days later and died the same day fromacute purulent bronchitis.
The post-mortemexamination showed that the empyema had com-pletely
resolved.
Cases of Empyema complicating NeoplasmCase 17. Male, aged 5i.
Neoplasm of left
bronchus complicated by pneumococcal empyema.Three ouices pus
removed at single aspiration.Intramuscular penicillin, 6o,ooo units
four-hourly for 28 days. Five injections of 240,000units
intrapleural penicillin on alternate days.Considerable temporary
improvement, but died53 days after admission from extensive
carcinoma,originating in left bronchus. The post-mortemexamination
showed that the empyema hadalmost entirely resolved, leaving only a
fewadhesions in the pleural space.
Case 21. Male, aged 49. Right leg amputatedfor sarcoma, two
years before present illness.Admitted to hospital with secondary
sarcoma of
478 Se-ptember I1948
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Sebtemnber I948 ELLIOTT and YOUNG: Treatment of Acute Emivcma
Thoracis 47g
.... ...:....
(Cse i--OnadmissiDn. (ase 6--I I mlOnths later.
--
Case 7.-On admission. Case 7-I15 months later.
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*6a POST GRADUATE MEDICAL JOURNAL September 1948
Case i6.-On admission. Case i6.-8 months later.
both lungs, with right-sided empyema, the pus*from which grew B.
Pfeiffer which was penicillinsensitive. Thick pus; two ounces
removed atsingle aspiration. Intramuscular penicillin 6o,ooounits
four-hourly for eight days. Six injections of250,000 units
intrapleural penicillin on alternatedays. Considerable improvement
in general con-dition; symptoms and signs caused by
empyemadisappeared. Patient returned home after 47 daysin
hospital.
'DiscussionButler and others (i944) treated i8 cases of
:acute empyema by aspiration and the injection ofintrapleural
penicillin en alternate days. Peni-cillin sensitive organisms were
grown in I 7 of-these cases; in the remaining case the culture
ofthe pleural fluid was sterile. The dose of intra-pleural
penicillin used by these authors was-relatively small (usually
20,000 units or less) andno intramuscular penicillin was given,
becausethe supply of the antibiotic was limited at thattime. The
results in this series of cases were onlymoderately satisfactory
and pleural thickeningoccurred in several of them. Although the
smalldoses of intrapleural penicillin used were suffi-cient to
sterilize the pus, recurrence of infectionoccurred in four cases
and in other cases minute
gram-positive cocci were repeatedly found infilms after
sterilization. The amount of intra-pleural penicillin given would
be insufficient toproduce a continuous bacteriostatic level in
theblood-stream; hence the antibiotic would notreach the underlying
disease.
Florey and Heatley (I945) found that injectionof 240,000 units
of penicillin into a pleural cavityafter aspiration of an effusion
gave a bacterio-static concentration of the drug in the
blood-stream for about 48 hours. Roberts and others(1945) pointed
out that absorption through thewalls of an established empyema
cavity might beslower than through the healthy pleura. Thesewriters
treated I2 cases of acute-,empyema withaspiration and intrapleural
penicillin as a pre-liminary to rib-resection and drainage. In
onlyone of these twelve cases was the empyema in theearly invasive
stage when treatment was started.The doses of intrapleural
penicillin used weresmall, the average being 30,000 units
initiallyand then 20,000 units at 48-72 hours intervals.No
intramuscular penicillin was given. Theseauthors found that poorly
staining bacteria mightbe seen in a gram film after the pus had
becomesterile. In two such cases, recrudescence of theinfection
occurred and the writers thereforerecommended that at least three
and preferably
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September 1948 ELLIOTT and YOUNG: Treatment of Acute Empyema
Thoracis 48!
more injections should be given subsequent tosterilization.
Fatti, Florey and others (I945) treated 24 casesof acute empyema
with penicillin, using varioustechniques. The technique which they
foundmost successful was repeated aspiration and theinjection of
intrapleural penicillin, followed byintercostal drainage and the
instillation of furtherdoses of penicillin. Intercostal drainage
was doneas soon as the effusion became frankly purulent.These
authors did not give intramuscular peni-cillin, but relied on using
relatively large doses ofintrapleural penicillin, (240,000 units
everysecond day before intercostal drainage and 6o,ooounits twice
daily in the toxaemic phase after inter-costal drainage) to
maintain a continuous bac-teriostatic concentration of the drug in
the blood-stream. Although these writers considered thatearly
intercostal drainage was the method ofchoice in the treatment of
acute empyema, theypointed out that it had two diasdvantages:-(i)
it was more difficult to ensure continuousretention of penicillin
with this method thanwhen aspirations on alternate days were
beingdone and (ii) the frequent interference for instil-lation of
penicillin favoured the introduction ofair and collapse of the lung
and prevented thefluid instilled from coming in contact with
thewhole of the affected pleural surfaces.
Brock and Holmes Sellors (i947) stated that inthe early
formative stages of pleural suppurationdrainage was both
unnecessary and dangerousand that penicillin therapy was most
likely to besuccessful in early cases. For mature empyemathey
recommended rib-resection and drainage.They emphasized the
importance of breathingexercises based on active, powerful and
concen-trated inspiratory efforts. These exercises couldbe started
from the onset of the condition.Our series of cases shows that good
results
can be obtained by a combination of intramuscularpenicillin with
repeated aspiration and injectionof intrapleural penicillin in
acute empyema due tosensitive organisms, provided that treatment
isbegun early in the disease and that the size of theeffusion is
not unduly large. Unless the possibilityof empyema is continually
borne in mind whenpneumonia is being treated with penicillin, it
maybe overlooked in its early stages. In two cases inour series,
the empyema appeared while thepatient was afebrile. In one of
these, the pleuralfluid was seropurulent and grew
StaphylococcusAureus on culture; in the other the fluid was
thick, greenish pus and grew StreptococcusViridans.We consider
that while acute toxaemic symp-
toms are present, intramuscular penicillin shouldbe given in
addition to intrapleural penicillin, asthis method ensures that the
underlying diseasecausing the empyema is adequately treated.Our
patients received intramuscular penicillin forfrom 7-2I days
according to the duration of theacute toxaemic phase. The dose
given in mostcases was 6o,ooo units four-hourly, which wehave found
to maintain a continuous bacterio-static concentration in the
blood-stream even incases where no intrapleural penicillin is
beingadministered.The pleural cavity must be aspirated as com-
pletely as possible through a wide-bore needle.Penicillin does
not mix readily with purulentfluids and it should therefore be
given intra-pleurally in 20 ml. of normal saline. In order toensure
the maximum local affect and to preventa recurrence of infection,
we consider that largedoses of intrapleural penicillin should be
given.In most of our cases doses of 250,000 units weregiven on
alternate days until no fluid was obtainedon aspiration, The
maximum number of aspira-tions necessary in any one case was
I4.
Breathing exercises of the type recommended byBrook and Holmes
Sellors (I947) should be startedas soon as the patient is able to
do them.
SummaryTwenty-two cases of acute empyema thoracis
were treated with intramuscular penicillin com-bined with
repeated aspirations and the injectionof intrapleural penicillin.
This series of casesshows that good results can be obtained by
thismethod in acute empyema due to penicillin sen-sitive organisms,
provided that treatment is begunearly in the disease and that the
size of the effusionis not unduly large.The importance of early
diagnosis has been
emphasized ; also the necessity for giving adequatedoses of
penicillin both by the intramuscular andthe intrapleural route.
Breathing exercises mustbe started early to obtain good functional
results.
BIBLIOGRAPHY
BROCK, R. C., HOLMES SELLORS, T. (1947), Proc. roy. Soc.Med. 40,
645.
BUTLER, E. C. B., PERRY, K. M. A., VALENTINE, F. C. 0.(944),
Brit. Med. J. ii, 171.
FATTI, L., FLOREY, M. E., JOULES, H., HUMPHREY, J. H.,SAKULA, J.
(I946), Lancet i, 257 and 295.
FLOREY, M. E., HEATLEY, N. G. (I945), Lancet i, 748.ROBERTS, J.
E. H., TUBBS, 0. S., BATES, M. (I945) Lancet i, 39.
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