One
of the strongest arguments in favour of performing rib resection in all cases
of localized empyema is that this provides an opportunity to remove all the
fibrin from the cavity. It is now possible to obtain commercially enzymes which
are capable of breaking down within the human body the solid constituents of an
inflammatory exudate. These enzymes, which are derived from the culture of
haemolytic streptococci, are known as streptokinase and streptodornase. The
former breaks down fibrin and the latter leads to the
dissolution of
desoxyribose nucleoprotein, which is largely responsible for the viscosity of
pus (Sherry, Tillett, and Read, 1950). It is possible that the intrapleural
injection of these enzymes may obviate the necessity for drainage of some cases
of acute empyema but it would be unwise to recommend this as a routine form of
treatment until these ferments have received more extensive trial. They are
likely to be of particular value in empyemas which arise from infection of a
haemothorax.
During
recent years some surgeons have tried to reduce the period of convalescence by
first sterilizing the empyema with intrapleural chemotherapy and then treating
the residual cavity by decortication (see page 44). Complete
decortication followed by an uncomplicated convalescence certainly gives quick
results but decortication is a major operation compared with rib-resection
drainage and is not always followed by complete and rapid
re-expansion of the lung. It is therefore advisable to reserve this form of
treatment for those patients who are seen in the first instance several weeks
after the optimum time for external drainage.
