(2)
Empyema secondary to subphrenic abscess.—Reference is made above to Harley's
review of 182 cases of subphrenic abscess (Harley, 1949), in which he found
that empyema occurred in 29 per cent, but that 50 per cent of these cases
followed injury to the diaphragm, caused by transpleural drainage, a
penetrating wound or transpleural aspiration (Fig. 5). On the other hand, he
found that a serous pleural effusion occurred in 25 per cent. This means that,
if the diaphragm is uninjured, a pleural effusion arising in the course of a
subphrenic abscess is more likely to be serous than suppurative, which
emphasizes the importance of diagnostic aspiration in these cases. A serous
effusion will clear up spontaneously provided that the subphrenic abscess is
drained satisfactorily. An infected effusion should receive treatment similar
to that described above for a post-pneumonic empyema. When the empyema is
localized and ready for external drainage, the site for rib resection should be
chosen by the method described above and sshould be separate from
the wound made to drain the subphrenic abscess.
(3)
Empyema secondary to bronchiectasis.—If the infection associated with
bronchiectasis extends into the lung parenchyma, the patient suffers an acute
febrile episode,., usually described as pneumonia. In some cases, if the
pleural space is not obliterated by adhesions, the infection spreads further
and gives rise to an empyema. This possibility should not be forgotten because
the diagnosis is apt to be missed, so that the empyema becomes chronic, and
then, if a bronchopleural fistula develops, the increased expectoration is
attributed to an exacerbation of the bronchial infection.
(4)
Empyema secondary to lung abscess.—If a foetid lung abscess ruptures
into the pleural space, the patient often becomes dangerously ill within a few
hours. In these cases the injection of penicillin into the stinking pyopneumothorax
is often life-saving.
(5)
Empyema secondary to bronchiogenic carcinoma.—In patients of cancer age who
develop an empyema, the possibility of an underlying growth should always be considered,
particularly in males, and if the acute illness was preceded by a considerable
period of lassitude or by symptoms of bronchial irritation. In cases of doubt,
the patient should be subjected to bronchoscopy before deciding on treatment of
the empyema. If a growth is found, the presence of the empyema does not exclude
the possibility of successful resection. If there are other factors indicating
that the growth is inoperable, every effort should be made to control the
empyema by aspiration and intrapleural chemotherapy, so that external drainage may be avoided, for a discharging wound only
adds to the miseries of a dying patient.
(6) Empyema due to actinomycosis.—Infection of the pleural cavity by
actino
mycosis characteristically produces a thin layer of pus with much loculation,
but, exceptionally, a single cavity simulating a postpneumonic empyema occurs.
Infection of the pleura is often followed by much pain and later by induration of
the chest wall and sinus formation. Drainage operations are rarely required,
for almost all cases clear up completely and permanently as a result of prolonged
and intensive systemic penicillin therapy. It is suggested that at least 2,000,000
units should be given daily for a minimum period of 6 weeks.
mycosis characteristically produces a thin layer of pus with much loculation,
but, exceptionally, a single cavity simulating a postpneumonic empyema occurs.
Infection of the pleura is often followed by much pain and later by induration of
the chest wall and sinus formation. Drainage operations are rarely required,
for almost all cases clear up completely and permanently as a result of prolonged
and intensive systemic penicillin therapy. It is suggested that at least 2,000,000
units should be given daily for a minimum period of 6 weeks.
