The Management of Pure Tuberculous and Mixed Infection Empyemata

¹ Department of Medicine, Sea View Hospital, Staten Island, New York.

1. Ninety-eight cases of frankly purulent tuberculous or mixed infection empyemas are categorized according to the Ornstein classification (discussed in the text). This division takes cognizance of the physical aspect of the pus—color and consistency, the organisms present therein, the condition of the underlying lung, whether controlled (sputum negative for the tubercle bacillus) or uncontrolled (sputum positive for the tubercle bacilli), the presence of chest wall infections (abscesses, sinuses, empyema necessitatis), and finally what constitutional effects the empyema has upon the patient.

2. In every instance the plan of treatment was determined by the condition of the underlying lung—whether controlled or uncontrolled. The aims to be accomplished in these two groups without broncho-pleural fistulae were as follows:

A. Controlled Lung:

1. Completely reexpand the lung and obliterate the pleural cavity thus removing a source of infection.

2. This also prevents the subsequent formation of empyema necessitatis as well as other chest wall infections.

3. Reexpansion restores good functioning lung tissue thereby increasing the vital capacity.

4. In certain cases where the lung fails to reexpand because of atelectasis, obstruction of the major bronchi, pulmonary fibrosis and a constricting thickened pleura enveloping the lung, the purpose of treatment is to prevent the re-formation of pus or change its consistency into thin serous fluid thus rendering it relatively innocuous.

B. Uncontrolled Lungs:

1. Reexpand the lung and obliterate the pleural cavity. In this way a simple thoracoplasty suffices for the treatment of the lung obviating the need for the shocking and radical Schede operation which would have been necessary otherwise.

2. The removal of the fluid and reexpansion of the lung also permits a better thoracoplastic result and a higher number of apparent cures.

3. Symphysis of the visceral and parietal pleura with obliteration of the empyema cavity results in a rapid clearing of chest wall infections which developed because of the original empyema.

4. Where continued pneumothorax is necessary for closure of pulmonary cavities, the rationale of therapy is to alter the empyema fluid so that the danger of chest wall infection is minimized.

5. In instances of severe toxemia treatment is indicated. The constitutional improvement makes the patient a better surgical risk, where operation is warranted.

3. The results under treatment with detergent solutions were dramatic and gratifying. The pus was thinned after the first few irrigations, the bacterial count was lowered and the virulence of the tubercle bacilli was reduced. Chest wall infections became a negligible factor; the temperature became normal and the general well being of the patient was soon manifest. A large number of lungs were reexpanded completely with oxygen lavage and the empyema cavity obliterated (48 cases).

4. The presence of a broncho-pleural fistula is a grave danger to the life of the individual and must always be considered a surgical problem. Eighty-six cases operated upon over a period corresponding with that during which we were treating our non-surgical group showed the following results:

Cured ..............34 %

Unimproved ..........19.5%

Deaths .............46.5%