Acute Empyema in Children: Duration of Illness Prior to Treatment A Factor in Mortality Rate

Medical Clinics of North America September, 1937. Baltimore Number

CONTRIBUTION BY DRS. C¥RUS F. HORINE BALTIMORE, MD. AND GEORGE S. BAKER ROCHESTER, MINN. ACUTE EMPYEMA IN CHILDREN: DURATION OF ILLNESS PRIOR TO TREATMENT A FACTOR IN MORTALITY RATE THE modern conception of the basic principles in the management of pleural empyema was established by the report of the Empyema Commission l of the United States Army in 1918. This work has stimulated considerable interest during the past twenty years in the creation of better methods of treatment. The concentration of thought in many instances has been centered upon various methods of technic which are a revival of the principles of suction, siphonage or valvular action. Many authors have claimed that their results are primarily or entirely due to some particular method of operation. A close scrutiny of the many statistical reports bare conflicting evidence and leave one in a quandary as to which is the best operative procedure. It is to be admitted that variable percentages in the reports of death rates may be influenced by the type and virulence of the infection, or by monthly and seasonal variations. These factors will affect mortality rates regardless of the type of treatment. The object of this report is to stress with particular emphasis a point which has heretofore received little mention. The particular point for discussion is: the duration of illness prior to treatment as a factor in empyema complications as well as a factor to be considered in the deduction of mortality rates irrespective of the type of operative procedure.. . The I3 67

I368

CYRUS F. HORINE, GEORGE S. BAKER

duration of illness has considerable bearing on the development of complications, from which, in most instances, death must be attributed. Patients rarely die from empyema per se. Death may be due to septicemia, meningitis, brain abscess, pericarditis, lung abscess, liver abscess or peritonitis. One frequent complication not to be overlooked is postoperative pneumonia in the contralateral lung. Our information is based on a study of 103 cases of acute empyema in children under thirteen years of age who were

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Fig. 95.-This chart represents a study of the duration of illness, in weeks, prior to admission. The death and recovery cases are bracketed in separate columns. The smaller figures indicate the number of cases for the particular ages while the larger figures represent the total numbers in each square, Note the heavy line of demarcation between the third and fourth weeks in duration of illness. Twelve deaths occurred in the younger children who were ill more than three weeks prior to admission and treatment.

treated at the University Hospital from 1924 to 1934. The usual statistical findings in this group parallel those of similar reports found in the general hospital series. The duration of illness prior to treatment was determined conclusively in 93 of the 103 cases. Twelve of the 16 deaths occurred in patients who had been ill more than three weeks. In the group of recoveries, 70 cases were ill three weeks or less, while 7 cases had been ill more than three weeks prior to r~cei:ving treatment. A sharp line of demarcation between the

ACUTE EMPYEMA IN CHILDREN

fatal and the recovering cases fell between three and four weeks from the onset of the initial illness (Fig. 95). It is a striking fact that no death occurred in the 44 children who were between six and twelve years of age (Fig. 96). The cause of death in 14 cases was proved by necropsy to be one or more of the complications mentioned above. Why did these deaths occur? With this point in mind the question was studied with respect to the type of infection and the duration of illness. Most of the deaths occurred irrespective of the type of infection in those cases who had been ill 20

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more than three weeks and many recoveries were found in the group who had been ill three weeks or less (Fig. 97). It is reasonable to suspect that the delay in receiving treatment is due to the late diagnosis of pneumonia and empyema in the very young children. Complications are more apt to follow as a result of this delay. Therefore, higher mortality rates are to be expected. The treatment in some of this series of cases consisted of aspiration alone; in others, aspiration combined with open and closed methods of drainage with and without rib resection was done. The results are not attribut-

CYRUS F. HORINE, GEORGE S. BAKER 1927 Recoveries age organism 5 pneumococcus 7 pneumOCOCCU3 3 3 pneumococcus 5 streptococcus and pneumococcus pneumococcus

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miliary lung abscesse5 pericarditis peritonitis

Fig. 97.-The solid curve in the graph shows the mortality rate per ye·ar in the 103 cases of empyema. The dotted curve represents the percentage of cases (five years of age or less) for each year. It is to be noted that the variable mortality rates for different years are not due entirely to the fact that most cases were in the very young age group. The high percentage of younger children in 1931 shows a comparatively low mortality rate. The mortality rates for 1926 and 1929 are tabulated with the ages, recoveries, duration of illness and type of infection. The duration of illness is an important contributing factor in these years of higher death rates. There are no deaths in 1927 and 1934. Note the duration of illness before admission, in the tabulated-cases for these two years.

ACUTE EMPYEMA IN CHILDREN

able to anyone particular method of treatment. In these 103 cases there was not a single fatality among the group that developed empyema while being treated in the hospital. CONCLUSIONS

Any child suffering from suspected pneumonia, particularly those under six years of age, who show little or no improvement after ten days from the onset of illness, should have an x-ray examination of the chest. It is an ordinary precaution. Early recognition with proper treatment will greatly reduce the mortality in empyema. It is not to be construed that the plea for early diagnosis is also an appeal for immediate operation after the diagnosis has been made. The individual factors i~ each individual case, such as the type and virulence of infection, the general condition of the patient, the consistency' of the pus and the location and character of the empyema1 should be some of the determining factors in selecting the' time and plan of treatment. The duration of illness prior to treatment may be a helpful index in the prognostication of complications and mortality rates. BIBLIOGRAPHY

1. Empyema Commission of the United States Army: Cases of Empyema at Camp Lee, Va., Jour. Amer. Med. Assoc., 71: 366-443, 1918.