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EMPYEMA THORACIS TREATED WITH PENICILLIN AND ASPIRATION ONLY
924
EMPYEMA THORACIS TREATED WITH PENICILLIN AND ASPIRATION ONLY RICHARD ASHER M.D. Lond., M.R.C.P.
DEWI DAVIES M.D. Lond., M.R.C.P.
PHYSICIAN
REGISTRAR
CENTRAL MIDDLESEX HOSPITAL
IT is
important,
in
judging
the effectiveness of
a
treatment, to decide not only whether it should work
but also whether it does work. There are good reasons why 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 certain advantages. Here are described twelve consecutive cases of empyema admitted under one medical firm between October, 1947, and April, 1949. All were treated with systemic and intrapleural penicillin without drainage
except repeated aspirations. Brock (1947) says : Many of the cures of empyema by aspiration are really It is much less likely cures of early pleural infection. that a mature or nearly mature empyema can be cured by aspiration alone, simply because of the adverse mechanical factors present in the thick exudate, rigid or partially rigid "
walls, and massive fibrin clots.... Penicillin is
not
Xhe most striking features at follow-up were the absence of symptoms and the normality in size, shape, and expansion of the affected hemithorax compared with its fellow. At the follow-up ten patients had apparently recovered completely, both clinically and radiologically. Case 12 undoubtedly had bronchiectasis before he developed his empyema ; therefore its detection afterwards is not significant. Case 11 developed a minute area of bronchiectasis. She had by far the smallest empyema in the series, but a rather severe pneumonia. It is difficult to believe that surgical drainage would have prevented the 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 figures given by Fatti et al. (1946), where recovery was judged complete when the sinus healed-i.e., a mean of fifteen weeks for empyemas treated purely surgically, and seven weeks 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 return to normal work, which in this series was 9-17 weeks, the mean being 12 weeks.
a
CASE-RECORDS
scavenger, it cannot clear up the battlefield ... the correction of the mechanical effects of infection is too much for the bodily resources. To delay or to withhold surgical help to clear up the battlefield is to harm the patients ; at the least, increasing the morbidity of his illness and often causing his death."
Case I.-A labourer, aged 57, developed a pneumonia which did not respond to sulphonamides. After a fortnight he was admitted to hospital with a large empyema. Culture of the pus grew a non-haemolytio streptococcus, and eighteen aspirations removed 270 oz. of fluid. The aspirated pus became sterile on culture after five days, and organisms disSuch authoritative and logical opinion is not to be appeared from the smear by the fourteenth day. The lightly disregarded, but some cases of empyema receiv- patient became apyrexial in six days. He was discharged ing penicillin as a preliminary to drainage appeared to be from hospital after eight and a half weeks, and returned progressing so well that it seemed reasonable to wonder to work sixteen weeks after admission. if it was true that " the correction of the mechanical Follow-up.-Two and three-quarter years later he was quite well. There was slightly diminished movement of the effects of infection is too much for the bodily resources." affected chest, but the circumference of each side was equal. It seemed justifiable to follow John Hunter’s famous " " Radiography showed slight pleural thickening, and’ a the think not Why try experiment ? suggestion: Why bronchogram was normal. TECHNIQUE Case 2.-A man, aged 26, was admitted with a postPus or infected fluid being encountered, the pleural pneumonic empyema in the fourth week of his illness. The a penicillin-sensitive Staph. aureus. The chest was cavity was aspirated with a 20-ml. syringe and two- pus grew on nine occasions and 34 oz. of pus removed. Culture aspirated as as and penicillin 500,000 became sterile in sixteen days and smears negative in twentyway tap completely possible units injected into it. In addition systemic penicillin six days. The patient’s temperature became normal in 200,000 units was given eight-hourly. Subsequent thirteen days. He was discharged in six and a half weeks, aspirations with intrapleural penicillin 200,000-500,000 and returned to work twelve weeks after admission. units were usually done at intervals of 1-3 days, dependFollow-up.-He was well two and a half years later, and the side was 1/2 in. greater in circumference than the other. affected evidence of on the clinical further and radiological ing The costophrenic angle was obliterated, and a bronchogram pus formation and the response of the patient’s fever and general health. Aspirations were repeated at lengthen- normal. Case 3.-A man, aged 67, a month before admission ing intervals until-no pus could be obtained and the a lobar pneumonia and was treated with sulphonwere developed fit. exercises patient appeared performed amides. He Breathing relapsed and was admitted with a pneumococcal throughout treatment. His haemoglobin was 48 %. His chest was empyema. FOLLOW-UP aspirated on eight occasions and 36 oz. of pus removed. Culture became sterile in seven days and smears negative One patient could not be traced. The other eleven have been followed as outpatients and at the time of in ten days. The patient was discharged in four and a weeks, and returned to work ten weeks after admission. writing have all reattended for questioning, chest half and a quarter years later he was at work Follow-up.-Two measurements, straight radiography, and bronchoand had a mild cough, as before his empyema. There was The graphy. length of follow-up varies from sixteen slightly diminished expansion of the affected side, but the months to thirty-three months. circumferences were equal. Straight radiography and bronchography were normal. RESULTS Case 4.-A man, aged 54, had pneumonia a month before There were no deaths among the twelve patients, admission. He relapsed after three weeks and was admitted most of whom showed a rapid improvement in fever and with an empyema, which consisted of thick pus which grew symptoms from the first aspiration. Fever usually Strep. viridans. Seven aspirations removed 60 oz. of pus. Culture was sterile in four days and smear negative in twenty settled in fourteen days. The pus became sterile on days. The patient became apyrexial in three weeks, was culture in about seven days (penicillinase was not used) discharged after eight weeks, and returned to work twelve and organisms persisted in smears for about fourteen days. and a half weeks after admission. The pus disappeared (or, more accurately, none could be Follow-up.-Two and a quarter years later he was well, obtained by aspiration) after an average of forty days. apart from a slight morning cough which he had had for many The longest time pus persisted to be found was seventyyears. Physical examination was negative, the costophrenio three days, and the shortest seven days. angle obliterated, and a bronchogram normal. ’
925 Case 5.-A housewife, aged 21, had had winter bronchitis since childhood and mild asthmatic attacks for two years. She was six months pregnant when admitted with a staphylococcal 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 obtained still 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 and The pleural pus still grew a Staph. aureus. was readmitted. Penicillin was injected into the pleural space on one occasion
only. Pregnancy proceeded normally. Follow-up.-A year and a half later radiological evidence of tuberculosis appeared in the other lung. Two and a quarter years later the patient had a very occasional cough. Physical examination was normal, and the affected lung was normal The tuberculous lesion was quiescent. on radiography. 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 pleural effusion. 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 aspiration. 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 with a synpneumonic empyema. The thin stinking pus grew an anaerobic streptococcus. Twelve aspirations removed 84 oz. of pus. Culture became sterile in four days and smears negative in twenty-six days. The patient became apyrexial in ten days, was discharged in seven weeks, and returned to work eleven weeks after admission. Follow-up.-Two years later he was rather emphysematous and had mild winter bronchitis. Chest movement and circumference were equal on both sides. The costophrenic angle was obliterated and a bronchogram normal. Case 8.-A housewife, aged 35, was admitted with a postpneumonic pneumococcal empyema. Twelve aspirations removed 9 pints of pus. Culture became sterile in three days, and smears negative in ten days, and the patient’s temperature became normal in five days. She was discharged after six weeks and had returned to full household duties three weeks later. Follow-up.-Eighteen months later the only abnormality was 1 in. diminution in circumference of the affected chest, expansion appearing equal. Radiography and bronchography were normal. Case 9.-A man, aged 27, was admitted with a pneumococcal pneumonia and a turbid effusion. Seven aspirations removed 47 oz., thick pus developing while intrapleural penicillin was continued. Culture was sterile, but smears The patient showed gram-positive cocci on two occasions. was discharged in eight weeks and returned to work seventeen weeks after admission. Follow-up.-Eighteen months later he had a slight smoker’s cough, as before this illness. The affected chest was 1/2 in. greater in circumference than the other. Radiography and bronchography were normal.
day of his pneumonia
eleven weeks after admission, having been delayed a month in waiting for a vacancy at a convalescent home. Follow-up.-Since then she has had a few bouts of cough and purulent sputum. Fourteen months after her discharge there was very slight diminution in expansion and a shrinkage of 3/4 in. on the affected side. Radiography was normal, but a bronchogram showed a minute area of bronchiectasis in 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 had In March, 1949, he was admitted an isolated haemoptysis. with a right-sided pneumonia and a sterile but polymorphonuclear effusion. Nine aspirations withdrew 22 oz., penicillin being given each time and the fluid changing to thick pus. The patient was discharged in seven and a half weeks and returned to work in twelve weeks. He remained well until April, 1950, when he was admitted with an abscess in the posterior basic segment of the right lower lobe. This healed completely with medical treatment. A bronchogram showed bronchiectasis of the right middle lobe and anterior basic segment of the lower lobe. Re-examination of the 1948 films showed an opacity corresponding to the affected anterior basic segment. In July, 1950, the patient had 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 containing polymorphs and organisms, did not constitute frank pus, have been excluded from this series though they did equally well. DISCUSSION
however efficiently performed, cannot the last trace of pus and debris. Natural repair and absorption seem to be capable of clearing up the remainder. This seems surprising, but lobar pneumonia is known to resolve rapidly, even though fibrin covers the lung at one stage. Even with rib resection no-one can be sure that the sucker has cleared every fragment of fibrin.
Aspiration,
remove
CONCLUSION
’
Case 10.—A man, aged 27, had lost his sight and both hands in 1941. He was admitted with a pneumococcal pneumonia and sterile effusion. He was unhappy and discharged himself against advice, still with an effusion. A fortnight later he was readmitted, coughing up copious foul pus, and was considered to have a bronchopleural fistula. The aspirated pus was also foul and contained gram-positive cocci but was sterile on culture. Ten aspirations removed 48 oz. of pus. The fistula closed in a few days, and the patient became apyrexial in three weeks. He was discharged after eight weeks. 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 costophrenic angle obliterated. A bronchogram was normal.
Case 1 l.-A housewife, aged 26, was admitted with lobar pneumonia and a small sterile effusion. No intrapleural medication was given, but after three and a half weeks a small empyema had formed. The thick pus contained Staph. aureus, and only 20 ml. was obtained at two aspirations. The patient improved steadily thereafter and was discharged
On the evidence of these cases there seems good reason for treating some cases of empyema with penicillin and aspiration only. It is not suggested that all cases should be so treated. None of the present cases was very chronic, and all had organisms sensitive, or likely to be sensitive, to penicillin. There may be chronic empyemas which have reached the stage where surgery is essential. However, since twelve unselected consecutive cases made satisfactory recoveries, it suggests that this form of treatment may be more often used than hitherto, especially with 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 a transient secondary invader was only found in four cases (Bact. coli in two cases, B. proteus in one case, and Strep. viridans in one case) towards the end of treatment, and no complication ensued therefrom. Frequent aspirations are no great hardship if done by an experienced man, and are probably no more discomforting than the changing of tubes and dressings which surgery requires. Also there are less smell, less soiling, and less work for the nurses. Perhaps very large empyemas would respond less well to this treatment. In the present series the largest amount of pus removed at one aspiration was 42 oz. and the largest total amount aspirated altogether was
270
oz.
We are most grateful to Dr. Frank Pygott for his help with the radiograms and Dr. Keith Ball for his advice and
criticism.
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.
EMPYEMA THORACIS TREATED WITH PENICILLIN AND ASPIRATION ONLY RICHARD ASHER M.D. Lond., M.R.C.P.
DEWI DAVIES M.D. Lond., M.R.C.P.
PHYSICIAN
REGISTRAR
CENTRAL MIDDLESEX HOSPITAL
IT is
important,
in
judging
the effectiveness of
a
treatment, to decide not only whether it should work
but also whether it does work. There are good reasons why 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 certain advantages. Here are described twelve consecutive cases of empyema admitted under one medical firm between October, 1947, and April, 1949. All were treated with systemic and intrapleural penicillin without drainage
except repeated aspirations. Brock (1947) says : Many of the cures of empyema by aspiration are really It is much less likely cures of early pleural infection. that a mature or nearly mature empyema can be cured by aspiration alone, simply because of the adverse mechanical factors present in the thick exudate, rigid or partially rigid "
walls, and massive fibrin clots.... Penicillin is
not
Xhe most striking features at follow-up were the absence of symptoms and the normality in size, shape, and expansion of the affected hemithorax compared with its fellow. At the follow-up ten patients had apparently recovered completely, both clinically and radiologically. Case 12 undoubtedly had bronchiectasis before he developed his empyema ; therefore its detection afterwards is not significant. Case 11 developed a minute area of bronchiectasis. She had by far the smallest empyema in the series, but a rather severe pneumonia. It is difficult to believe that surgical drainage would have prevented the 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 figures given by Fatti et al. (1946), where recovery was judged complete when the sinus healed-i.e., a mean of fifteen weeks for empyemas treated purely surgically, and seven weeks 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 return to normal work, which in this series was 9-17 weeks, the mean being 12 weeks.
a
CASE-RECORDS
scavenger, it cannot clear up the battlefield ... the correction of the mechanical effects of infection is too much for the bodily resources. To delay or to withhold surgical help to clear up the battlefield is to harm the patients ; at the least, increasing the morbidity of his illness and often causing his death."
Case I.-A labourer, aged 57, developed a pneumonia which did not respond to sulphonamides. After a fortnight he was admitted to hospital with a large empyema. Culture of the pus grew a non-haemolytio streptococcus, and eighteen aspirations removed 270 oz. of fluid. The aspirated pus became sterile on culture after five days, and organisms disSuch authoritative and logical opinion is not to be appeared from the smear by the fourteenth day. The lightly disregarded, but some cases of empyema receiv- patient became apyrexial in six days. He was discharged ing penicillin as a preliminary to drainage appeared to be from hospital after eight and a half weeks, and returned progressing so well that it seemed reasonable to wonder to work sixteen weeks after admission. if it was true that " the correction of the mechanical Follow-up.-Two and three-quarter years later he was quite well. There was slightly diminished movement of the effects of infection is too much for the bodily resources." affected chest, but the circumference of each side was equal. It seemed justifiable to follow John Hunter’s famous " " Radiography showed slight pleural thickening, and’ a the think not Why try experiment ? suggestion: Why bronchogram was normal. TECHNIQUE Case 2.-A man, aged 26, was admitted with a postPus or infected fluid being encountered, the pleural pneumonic empyema in the fourth week of his illness. The a penicillin-sensitive Staph. aureus. The chest was cavity was aspirated with a 20-ml. syringe and two- pus grew on nine occasions and 34 oz. of pus removed. Culture aspirated as as and penicillin 500,000 became sterile in sixteen days and smears negative in twentyway tap completely possible units injected into it. In addition systemic penicillin six days. The patient’s temperature became normal in 200,000 units was given eight-hourly. Subsequent thirteen days. He was discharged in six and a half weeks, aspirations with intrapleural penicillin 200,000-500,000 and returned to work twelve weeks after admission. units were usually done at intervals of 1-3 days, dependFollow-up.-He was well two and a half years later, and the side was 1/2 in. greater in circumference than the other. affected evidence of on the clinical further and radiological ing The costophrenic angle was obliterated, and a bronchogram pus formation and the response of the patient’s fever and general health. Aspirations were repeated at lengthen- normal. Case 3.-A man, aged 67, a month before admission ing intervals until-no pus could be obtained and the a lobar pneumonia and was treated with sulphonwere developed fit. exercises patient appeared performed amides. He Breathing relapsed and was admitted with a pneumococcal throughout treatment. His haemoglobin was 48 %. His chest was empyema. FOLLOW-UP aspirated on eight occasions and 36 oz. of pus removed. Culture became sterile in seven days and smears negative One patient could not be traced. The other eleven have been followed as outpatients and at the time of in ten days. The patient was discharged in four and a weeks, and returned to work ten weeks after admission. writing have all reattended for questioning, chest half and a quarter years later he was at work Follow-up.-Two measurements, straight radiography, and bronchoand had a mild cough, as before his empyema. There was The graphy. length of follow-up varies from sixteen slightly diminished expansion of the affected side, but the months to thirty-three months. circumferences were equal. Straight radiography and bronchography were normal. RESULTS Case 4.-A man, aged 54, had pneumonia a month before There were no deaths among the twelve patients, admission. He relapsed after three weeks and was admitted most of whom showed a rapid improvement in fever and with an empyema, which consisted of thick pus which grew symptoms from the first aspiration. Fever usually Strep. viridans. Seven aspirations removed 60 oz. of pus. Culture was sterile in four days and smear negative in twenty settled in fourteen days. The pus became sterile on days. The patient became apyrexial in three weeks, was culture in about seven days (penicillinase was not used) discharged after eight weeks, and returned to work twelve and organisms persisted in smears for about fourteen days. and a half weeks after admission. The pus disappeared (or, more accurately, none could be Follow-up.-Two and a quarter years later he was well, obtained by aspiration) after an average of forty days. apart from a slight morning cough which he had had for many The longest time pus persisted to be found was seventyyears. Physical examination was negative, the costophrenio three days, and the shortest seven days. angle obliterated, and a bronchogram normal. ’
925 Case 5.-A housewife, aged 21, had had winter bronchitis since childhood and mild asthmatic attacks for two years. She was six months pregnant when admitted with a staphylococcal 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 obtained still 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 and The pleural pus still grew a Staph. aureus. was readmitted. Penicillin was injected into the pleural space on one occasion
only. Pregnancy proceeded normally. Follow-up.-A year and a half later radiological evidence of tuberculosis appeared in the other lung. Two and a quarter years later the patient had a very occasional cough. Physical examination was normal, and the affected lung was normal The tuberculous lesion was quiescent. on radiography. 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 pleural effusion. 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 aspiration. 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 with a synpneumonic empyema. The thin stinking pus grew an anaerobic streptococcus. Twelve aspirations removed 84 oz. of pus. Culture became sterile in four days and smears negative in twenty-six days. The patient became apyrexial in ten days, was discharged in seven weeks, and returned to work eleven weeks after admission. Follow-up.-Two years later he was rather emphysematous and had mild winter bronchitis. Chest movement and circumference were equal on both sides. The costophrenic angle was obliterated and a bronchogram normal. Case 8.-A housewife, aged 35, was admitted with a postpneumonic pneumococcal empyema. Twelve aspirations removed 9 pints of pus. Culture became sterile in three days, and smears negative in ten days, and the patient’s temperature became normal in five days. She was discharged after six weeks and had returned to full household duties three weeks later. Follow-up.-Eighteen months later the only abnormality was 1 in. diminution in circumference of the affected chest, expansion appearing equal. Radiography and bronchography were normal. Case 9.-A man, aged 27, was admitted with a pneumococcal pneumonia and a turbid effusion. Seven aspirations removed 47 oz., thick pus developing while intrapleural penicillin was continued. Culture was sterile, but smears The patient showed gram-positive cocci on two occasions. was discharged in eight weeks and returned to work seventeen weeks after admission. Follow-up.-Eighteen months later he had a slight smoker’s cough, as before this illness. The affected chest was 1/2 in. greater in circumference than the other. Radiography and bronchography were normal.
day of his pneumonia
eleven weeks after admission, having been delayed a month in waiting for a vacancy at a convalescent home. Follow-up.-Since then she has had a few bouts of cough and purulent sputum. Fourteen months after her discharge there was very slight diminution in expansion and a shrinkage of 3/4 in. on the affected side. Radiography was normal, but a bronchogram showed a minute area of bronchiectasis in 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 had In March, 1949, he was admitted an isolated haemoptysis. with a right-sided pneumonia and a sterile but polymorphonuclear effusion. Nine aspirations withdrew 22 oz., penicillin being given each time and the fluid changing to thick pus. The patient was discharged in seven and a half weeks and returned to work in twelve weeks. He remained well until April, 1950, when he was admitted with an abscess in the posterior basic segment of the right lower lobe. This healed completely with medical treatment. A bronchogram showed bronchiectasis of the right middle lobe and anterior basic segment of the lower lobe. Re-examination of the 1948 films showed an opacity corresponding to the affected anterior basic segment. In July, 1950, the patient had 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 containing polymorphs and organisms, did not constitute frank pus, have been excluded from this series though they did equally well. DISCUSSION
however efficiently performed, cannot the last trace of pus and debris. Natural repair and absorption seem to be capable of clearing up the remainder. This seems surprising, but lobar pneumonia is known to resolve rapidly, even though fibrin covers the lung at one stage. Even with rib resection no-one can be sure that the sucker has cleared every fragment of fibrin.
Aspiration,
remove
CONCLUSION
’
Case 10.—A man, aged 27, had lost his sight and both hands in 1941. He was admitted with a pneumococcal pneumonia and sterile effusion. He was unhappy and discharged himself against advice, still with an effusion. A fortnight later he was readmitted, coughing up copious foul pus, and was considered to have a bronchopleural fistula. The aspirated pus was also foul and contained gram-positive cocci but was sterile on culture. Ten aspirations removed 48 oz. of pus. The fistula closed in a few days, and the patient became apyrexial in three weeks. He was discharged after eight weeks. 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 costophrenic angle obliterated. A bronchogram was normal.
Case 1 l.-A housewife, aged 26, was admitted with lobar pneumonia and a small sterile effusion. No intrapleural medication was given, but after three and a half weeks a small empyema had formed. The thick pus contained Staph. aureus, and only 20 ml. was obtained at two aspirations. The patient improved steadily thereafter and was discharged
On the evidence of these cases there seems good reason for treating some cases of empyema with penicillin and aspiration only. It is not suggested that all cases should be so treated. None of the present cases was very chronic, and all had organisms sensitive, or likely to be sensitive, to penicillin. There may be chronic empyemas which have reached the stage where surgery is essential. However, since twelve unselected consecutive cases made satisfactory recoveries, it suggests that this form of treatment may be more often used than hitherto, especially with 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 a transient secondary invader was only found in four cases (Bact. coli in two cases, B. proteus in one case, and Strep. viridans in one case) towards the end of treatment, and no complication ensued therefrom. Frequent aspirations are no great hardship if done by an experienced man, and are probably no more discomforting than the changing of tubes and dressings which surgery requires. Also there are less smell, less soiling, and less work for the nurses. Perhaps very large empyemas would respond less well to this treatment. In the present series the largest amount of pus removed at one aspiration was 42 oz. and the largest total amount aspirated altogether was
270
oz.
We are most grateful to Dr. Frank Pygott for his help with the radiograms and Dr. Keith Ball for his advice and
criticism.
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.