924

EMPYEMA THORACIS TREATED WITH

PENICILLIN AND ASPIRATION ONLY

RICHARD ASHERM.D. Lond., M.R.C.P.

PHYSICIAN

DEWI DAVIESM.D. Lond., M.R.C.P.

REGISTRAR

CENTRAL MIDDLESEX HOSPITAL

IT is important, in judging the effectiveness of atreatment, to decide not only whether it should workbut also whether it does work. There are good reasonswhy aspiration and penicillin alone should not cure

empyema, and sound theory in favour of surgical drainage.All the same, if penicillin alone does work it has certainadvantages. Here are described twelve consecutive casesof empyema admitted under one medical firm betweenOctober, 1947, and April, 1949. All were treated with

systemic and intrapleural penicillin without drainageexcept repeated aspirations.Brock (1947) says :

"

Many of the cures of empyema by aspiration are reallycures of early pleural infection. It is much less likelythat a mature or nearly mature empyema can be cured byaspiration alone, simply because of the adverse mechanicalfactors present in the thick exudate, rigid or partially rigidwalls, and massive fibrin clots.... Penicillin is not ascavenger, it cannot clear up the battlefield ... the correctionof the mechanical effects of infection is too much for thebodily resources. To delay or to withhold surgical helpto clear up the battlefield is to harm the patients ; at the

least, increasing the morbidity of his illness and oftencausing his death."Such authoritative and logical opinion is not to be

lightly disregarded, but some cases of empyema receiv-ing penicillin as a preliminary to drainage appeared to beprogressing so well that it seemed reasonable to wonderif it was true that " the correction of the mechanicaleffects of infection is too much for the bodily resources."It seemed justifiable to follow John Hunter’s famous

suggestion: " Why think Why not try the experiment ?

"

TECHNIQUE

Pus or infected fluid being encountered, the pleuralcavity was aspirated with a 20-ml. syringe and two-way tap as completely as possible and penicillin 500,000units injected into it. In addition systemic penicillin200,000 units was given eight-hourly. Subsequentaspirations with intrapleural penicillin 200,000-500,000units were usually done at intervals of 1-3 days, depend-ing on the clinical and radiological evidence of furtherpus formation and the response of the patient’s fever andgeneral health. Aspirations were repeated at lengthen-ing intervals until-no pus could be obtained and thepatient appeared fit. Breathing exercises were performedthroughout treatment.

FOLLOW-UP

One patient could not be traced. The other elevenhave been followed as outpatients and at the time ofwriting have all reattended for questioning, chestmeasurements, straight radiography, and broncho-graphy. The length of follow-up varies from sixteenmonths to thirty-three months.

RESULTS

There were no deaths among the twelve patients,most of whom showed a rapid improvement in fever andsymptoms from the first aspiration. Fever usuallysettled in fourteen days. The pus became sterile onculture in about seven days (penicillinase was not used)and organisms persisted in smears for about fourteen days.The pus disappeared (or, more accurately, none could beobtained by aspiration) after an average of forty days.The longest time pus persisted to be found was seventy-three days, and the shortest seven days.

Xhe most striking features at follow-up were theabsence of symptoms and the normality in size, shape, andexpansion of the affected hemithorax compared with itsfellow.

At the follow-up ten patients had apparently recoveredcompletely, both clinically and radiologically. Case 12undoubtedly had bronchiectasis before he developed hisempyema ; therefore its detection afterwards is not

significant. Case 11 developed a minute area of bron-chiectasis. She had by far the smallest empyema inthe series, but a rather severe pneumonia. It is difficultto believe that surgical drainage would have preventedthe development of bronchiectasis in her case.The length of stay in hospital was 41/2-11 weeks, the

mean being 71/2 weeks.Since none of these cases had a sinus to heal, the

length of illness cannot fairly be compared with figuresgiven by Fatti et al. (1946), where recovery was judgedcomplete when the sinus healed-i.e., a mean of fifteenweeks for empyemas treated purely surgically, and sevenweeks for cases treated with penicillin via intercostal drain.Some indication of the rate of recovery is shown by

the interval between admission to hospital and returnto normal work, which in this series was 9-17 weeks,the mean being 12 weeks.

CASE-RECORDS

Case I.-A labourer, aged 57, developed a pneumoniawhich did not respond to sulphonamides. After a fortnighthe was admitted to hospital with a large empyema. Cultureof the pus grew a non-haemolytio streptococcus, and eighteenaspirations removed 270 oz. of fluid. The aspirated pusbecame sterile on culture after five days, and organisms dis-appeared from the smear by the fourteenth day. Thepatient became apyrexial in six days. He was dischargedfrom hospital after eight and a half weeks, and returnedto work sixteen weeks after admission.Follow-up.-Two and three-quarter years later he was quite

well. There was slightly diminished movement of theaffected chest, but the circumference of each side was equal.Radiography showed slight pleural thickening, and’ abronchogram was normal.Case 2.-A man, aged 26, was admitted with a post-

pneumonic empyema in the fourth week of his illness. The

pus grew a penicillin-sensitive Staph. aureus. The chest was

aspirated on nine occasions and 34 oz. of pus removed. Culturebecame sterile in sixteen days and smears negative in twenty-six days. The patient’s temperature became normal inthirteen days. He was discharged in six and a half weeks,and returned to work twelve weeks after admission.Follow-up.-He was well two and a half years later, and the

affected side was 1/2 in. greater in circumference than the other.The costophrenic angle was obliterated, and a bronchogramnormal.

’

Case 3.-A man, aged 67, a month before admissiondeveloped a lobar pneumonia and was treated with sulphon-amides. He relapsed and was admitted with a pneumococcalempyema. His haemoglobin was 48 %. His chest was

aspirated on eight occasions and 36 oz. of pus removed.Culture became sterile in seven days and smears negativein ten days. The patient was discharged in four and ahalf weeks, and returned to work ten weeks after admission.Follow-up.-Two and a quarter years later he was at work

and had a mild cough, as before his empyema. There wasslightly diminished expansion of the affected side, but thecircumferences were equal. Straight radiography andbronchography were normal.

Case 4.-A man, aged 54, had pneumonia a month beforeadmission. He relapsed after three weeks and was admittedwith an empyema, which consisted of thick pus which grewStrep. viridans. Seven aspirations removed 60 oz. of pus.Culture was sterile in four days and smear negative in twentydays. The patient became apyrexial in three weeks, wasdischarged after eight weeks, and returned to work twelveand a half weeks after admission.Follow-up.-Two and a quarter years later he was well,

apart from a slight morning cough which he had had for manyyears. Physical examination was negative, the costophrenioangle obliterated, and a bronchogram normal.

925

Case 5.-A housewife, aged 21, had had winter bronchitissince childhood and mild asthmatic attacks for two years.She was six months pregnant when admitted with a staphylo-coccal pneumonia. She developed a synpneumonic empyema,the responsible Staph. aureu8 being penicillin-sensitive.Aspiration on seven occasions removed 77 oz. of pus. The

empyema was loculated, and the last specimen of pus obtainedstill contained scanty organisms. The patient became

apyrexial in fourteen days and was discharged in six weeks.A week later she coughed up a small residual empyema andwas readmitted. The pleural pus still grew a Staph. aureus.Penicillin was injected into the pleural space on one occasiononly. Pregnancy proceeded normally.Follow-up.-A year and a half later radiological evidence

of tuberculosis appeared in the other lung. Two and a quarteryears later the patient had a very occasional cough. Physicalexamination was normal, and the affected lung was normalon radiography. The tuberculous lesion was quiescent.Bronchography was not done.Case 6.-A labourer, aged 68, was admitted six days

after the onset of an extensive pneumococcal pneumonia.He developed toxic delirium, extensive purpura, and a pleuraleffusion. This was aspirated on seven occasions and 36 oz.was removed, the fluid eventually becoming thick pus.Pneumococci disappeared from the fluid after the first aspira-tion. The patient was discharged from hospital in seven weeks,and has not been traced for follow-up.Case 7.-A labourer, aged 60, was admitted on the seventh

day of his pneumonia with a synpneumonic empyema. Thethin stinking pus grew an anaerobic streptococcus. Twelveaspirations removed 84 oz. of pus. Culture became sterile infour days and smears negative in twenty-six days. The

patient became apyrexial in ten days, was discharged in sevenweeks, and returned to work eleven weeks after admission.Follow-up.-Two years later he was rather emphysematous

and had mild winter bronchitis. Chest movement andcircumference were equal on both sides. The costophrenicangle was obliterated and a bronchogram normal.Case 8.-A housewife, aged 35, was admitted with a post-

pneumonic pneumococcal empyema. Twelve aspirationsremoved 9 pints of pus. Culture became sterile in three days,and smears negative in ten days, and the patient’s temperaturebecame normal in five days. She was discharged after sixweeks and had returned to full household duties three weekslater.

’

Follow-up.-Eighteen months later the only abnormalitywas 1 in. diminution in circumference of the affected chest,expansion appearing equal. Radiography and bronchographywere normal.

Case 9.-A man, aged 27, was admitted with a pneumo-coccal pneumonia and a turbid effusion. Seven aspirationsremoved 47 oz., thick pus developing while intrapleuralpenicillin was continued. Culture was sterile, but smearsshowed gram-positive cocci on two occasions. The patientwas discharged in eight weeks and returned to work seventeenweeks after admission.

Follow-up.-Eighteen months later he had a slight smoker’scough, as before this illness. The affected chest was 1/2 in.greater in circumference than the other. Radiography andbronchography were normal.Case 10.—A man, aged 27, had lost his sight and both hands

in 1941. He was admitted with a pneumococcal pneumoniaand sterile effusion. He was unhappy and discharged himselfagainst advice, still with an effusion. A fortnight later hewas readmitted, coughing up copious foul pus, and wasconsidered to have a bronchopleural fistula. The aspiratedpus was also foul and contained gram-positive cocci but wassterile on culture. Ten aspirations removed 48 oz. of pus.The fistula closed in a few days, and the patient becameapyrexial in three weeks. He was discharged after eightweeks.Follow-up.-Sixteen months later he was well. There was

slight impairment of percussion note at the affected base,but no other signs. Radiography showed the costophrenicangle obliterated. A bronchogram was normal.Case 1 l.-A housewife, aged 26, was admitted with lobar

pneumonia and a small sterile effusion. No intrapleuralmedication was given, but after three and a half weeks asmall empyema had formed. The thick pus containedStaph. aureus, and only 20 ml. was obtained at two aspirations.The patient improved steadily thereafter and was discharged

eleven weeks after admission, having been delayed a monthin waiting for a vacancy at a convalescent home.

Follow-up.-Since then she has had a few bouts of coughand purulent sputum. Fourteen months after her dischargethere was very slight diminution in expansion and a shrink-age of 3/4 in. on the affected side. Radiography was normal,but a bronchogram showed a minute area of bronchiectasisin the posterior basic segment of the lower lobe.Case 12.-A boy, aged 19, had had severe pneumonia in

childhood. He had remained well, but in 1948 had hadan isolated haemoptysis. In March, 1949, he was admittedwith a right-sided pneumonia and a sterile but polymor-phonuclear effusion. Nine aspirations withdrew 22 oz.,

penicillin being given each time and the fluid changing tothick pus. The patient was discharged in seven and a halfweeks and returned to work in twelve weeks. He remainedwell until April, 1950, when he was admitted with an abscessin the posterior basic segment of the right lower lobe. Thishealed completely with medical treatment. A broncho-

gram showed bronchiectasis of the right middle lobe andanterior basic segment of the lower lobe. Re-examinationof the 1948 films showed an opacity corresponding to theaffected anterior basic segment. In July, 1950, the patienthad only slightly diminished movement of the right side,the circumferences being equal. He is awaiting lobectomy.

All these patients had pus in the pleural cavity. Other

patients, whose fluid in the pleura, though containingpolymorphs and organisms, did not constitute frank

pus, have been excluded from this series though theydid equally well.

DISCUSSION

Aspiration, however efficiently performed, cannotremove the last trace of pus and debris. Natural

repair and absorption seem to be capable of clearing upthe remainder. This seems surprising, but lobarpneumonia is known to resolve rapidly, even thoughfibrin covers the lung at one stage. Even with ribresection no-one can be sure that the sucker has clearedevery fragment of fibrin.

CONCLUSION

On the evidence of these cases there seems good reasonfor treating some cases of empyema with penicillin andaspiration only. It is not suggested that all cases shouldbe so treated. None of the present cases was verychronic, and all had organisms sensitive, or likely to besensitive, to penicillin. There may be chronic empyemaswhich have reached the stage where surgery is essential.

However, since twelve unselected consecutive cases madesatisfactory recoveries, it suggests that this form of treat-ment may be more often used than hitherto, especiallywith the increasing number and power of new antibiotics.The obvious advantages of the method are that the

cavity is kept closed and that there is no wound to heal.Secondary infection is less likely, and in this series atransient secondary invader was only found in fourcases (Bact. coli in two cases, B. proteus in one case, andStrep. viridans in one case) towards the end of treatment,and no complication ensued therefrom. Frequent aspira-tions are no great hardship if done by an experiencedman, and are probably no more discomforting than thechanging of tubes and dressings which surgery requires.Also there are less smell, less soiling, and less work for thenurses. Perhaps very large empyemas would respondless well to this treatment. In the present series the

largest amount of pus removed at one aspiration was42 oz. and the largest total amount aspirated altogetherwas 270 oz.

We are most grateful to Dr. Frank Pygott for his helpwith the radiograms and Dr. Keith Ball for his advice andcriticism.

REFERENCES

Brock, R. C. (1947) Proc. R. Soc. Med. 40, 645.Fatti, L., Florey, M. E., Joules, H., Humphrey, J. H., Sakula, J.

(1946) Lancet, i, 257, 295.