Aug., 19501 EMPYEMA NECESSITATIS : DINGLEY 337

Case report U. S., aged 25 years, male, transferred to this Original Articles institution on 5th April, 1949, from Military Hospital, Dehra Dun. The patient was having slight rise of tem- perature up to 99 ?F., cough with expectoration L EMPYEMA NECESSITATIS FOLLOW- and was on artificial pneumothorax treatment ING CLOSED INTRAPLEURAL (right). PNEUMONOLYSIS WITH History of present illness.?While on active A CASE REPORT! service, in the month of October 1948, the patient started getting temperature up to 101 ?F. By H. B.JDINGLEY, b.sc., m.b., b.s-, t.d.d. Later, cough started with slight expectora- Second Senior Assistant, Lady Linlithgow Sanatorium, tion and blood-stained sputum. Admitted to Kasauli (Simla Hills) Military Hospital where skiagram of the chest was taken, which revealed exudative of Almost all cases of pulmonary type lesion with a cavity in the upper and mid having artificial pneumothorax treatment, uni- right zone. Sputum on examination was for lateral or bilateral, require closed intrapleural positive A.F.B., diagnosis of tuberculosis was to upon the extent of pulmonary pneumonolysis improve and A.P. started on the side on the there is some made, right pulmonary collapse, though 24th 1948. diversity of views regarding its absolute indica- November, tions and contra-indications. Some workers do On admission into this institution.?General not consider it as an essential procedure where examination of the patient showed his condition the sputum is negative and cavity is apparently to be fair. closed, while others are of the opinion that all Physical examination of the chest.?Right cases having artificial pneumothorax treatment chest showed signs of pneumothorax with should have a trial of and deficient breath sounds and comparatively cauterization, if need be, irrespective of the fact resonant percussion note. Left chest : No whether adhesions are seen or not in the abnormal breath sounds. to all adhesions are skiagram. According them, Other abnormal find- not examina- systems.?No physical always visualized by radiological ings. examination showed moderate tion. The latest trend is that wherever adhesions X.-ray collapse of the right which was adherent are an of the preventing adequate collapse at the top with a broad adhesion and a patent diseased or are situated over the diseased focus, cavity. focus, closed intrapleural pneumonolysis should be done irrespective of Fluoroscopic examination.?Revealed the adhesion to be posterior. (1) whether A.F.B. are present or not in examination.?It was for the sputum, and Sputum positive A.F.B. (direct smear). (2) whether the cavity is closed or Blood examination.?(Schilling's count) : patent. Total .. 60 This has been based on the observation of neutrophil various workers, according to whom, lesions of (Stab Kernig's . . 20 the are no lung parenchyma, when there Segmented .. 40) adhesions, not only heal better, but quicker than when A.P. is maintained in the Eosinophil . . 6 being e presence of adhesions. By severing the adhesion Lymphocytes .. 30 and the from the chest wall we releasing lung Large monocytes .. 4 are avoiding respiratory trauma (Monaldi). The actual procedure is not completely devoid of E.S.R. 28 mm. 1st hour (Westergren) various complications, of which the most frequent and simplest is surgical emphysema, It was decided to maintain the A.P. on the the more serious being coagulation necrosis of right side and to do closed intrapleural pneu- the visceral stump leading to spontaneous monolysis as a supplementary operation, which pneumothorax with empyema. The other com- was done on 3rd August, 1949. plications frequently met with, are pleural Details of the operation.?The 1st. puncture effusions, and internal haemorrhage from the was made in the 3rd space mid-clavicular line intercostal vessels, as a result of injury to the and thoracoscope put in, which revealed one big Neighbouring vessels or from the lung paren- fleshy fold-like adhesion going posteriorly; the chyma. lung surface was bluish. No tubercles were A rare occurrence which was met with in visualized either on the surface of the adhesion was made in ?ne of our cases following closed intrapleural or the pleura. The 2nd puncture which showed pneumonolysis was the occurrence of empyema the 6th space mid-axillary line, necessitatis at the site of the puncture wound. the adhesion to be fairly broad and going to 338 THE INDIAN MEDICAL GAZETTE [Aug., 1950 the costovertebral gutter. Partial cauteriza- 14th December.?Three pints of pus were tion with enucleation of the adhesion was done aspirated from the and one lakh close to the chest wall with a very dull hot units of penicillin were put in. cauterization of the adhesion cautery. Complete 21,si December.?X-ray of the chest was done, was not as was sessile. The possible it very which showed the whole of the right chest to be sites of the were closed with punctures deep opaqufe with a very small amount of fluid. stitches and the patient advised to lie on the non- 24th December. ?10 cc. of P.A.S. solution operated side. Subsequent and periodic screen examination of the patient showed effusion in were put in the pleural cavity. the pleural cavity, which was showing increase 31 st December.?Following excessive cough- in quantity at each examination. With the ing, the swelling in the chest wall burst increase in the amount of fluid the patient and a small amount of thin yellowish creamy started getting some rise of temperature and pus came out. A clean dressing was applied dyspnoea even on resting in bed. and the patient was put in semi-recumbent with head and chest raised On 2nd September, 1949.?16 oz. of straw- posture upper up. coloured clear fluid were aspirated from the 2nd January, 1950.?Two pints of pus were pleural cavity. With the aspiration of the fluid, aspirated and one lakh units of penicillin and the patient was relieved of breathlessness and 1 gm. streptomycin solution were put into the temperature also came down to 99?F. pleural cavity. 24th September.?All of a sudden the patient Examination of pus was negative for A.F.B. had haemoptysis, which lasted for four days, Repeated examination of the pleurocutaneous following which his temperature rose up to sinus showed occasional thin yellowish discharge 104?F. to 105?F., for which he was adminis- out of it. It was decided to start ultra-violet tered streptomycin ^ gm. twice a day from 6th ray therapy locally on the sinus from 12th October, 1949. In all 20 gm. were given, with January. the result that his settled temperature again 13 th January.?26 oz. of thin pus were to 99?F. aspirated, 1 gm. streptomycin and one lakh units Routine fluoroscopic examination showed of penicillin were put in. In all the patient had 9 increase in the amount of fluid. exposures to the ultra-violet rays at 4 days' the last on 6th 19th November.?2nd aspiration was done interval, being February. and 36 oz. of thick pus were taken out; one lakh 13th February.?Aspiration of empyema was units of penicillin in 20 cc. normal saline were again done and 6 oz. of very thin pus were put into the pleural cavity. aspirated. 22nd November.?10 cc. of P.A.S. solution were Local examination of the pleurocutaneous put into the pleural cavity. sinus showed it to be apparently closed and no 29th November.?3rd aspiration was done, discharge was seen coming out for at least 7 16 oz. of pus were taken out and 10 cc. of days. P.A.S. were put into the pleural cavity. Subsequently the patient had three stages of 9th December.?10 cc. of P.A.S. solution were thoracoplasty and nine ribs were resected. into the put pleural cavity. Follow up of the case has revealed the sinus 13th December.?Patient started complain- healed; empyema space obliterated; cavity ing of a painful swelling in the chest which apparently closed; and sputum negative for showed some increase in size on coughing. A.F.B. For three months the patient has had no constitutional He is on On examination it was found to be at the site symptoms. light exercise these of the old puncture wound of the intrapleural days. pneumonolysis operation in the 3rd space mid- clavicular line. The swelling could be reduced Discussion on gentle pressure and it also revealed gurgling. Of the "341 cases who closed It was filling again after coughing. had intrapleural done in the sanatorium since The skin was pneumonolysis superficial shining, stretched, 1941, this complication occurred in only slightly injected and tender. slightly Taking one case reported above. The case under into consideration the a underlying empyema, review before undergoing closed intrapleural diagnosis of empyema necessitatis was made. pneumonolysis had a patent cavity and Screen examination showed nearly half of the a broad adhesion, which was apparently pleural cavity to be full of fluid. A soft gauze keeping the cavity open. Sputum was positive and cotton were pad placed at the site of the for A.F.B., hence closed intrapleural pneumono- swelling and a binder was applied. The patient lysis was done. Clinically it has been observed was to instructed press the swelling with hand that incidence of pleural effusion and empyema is while coughing and to lie on the opposite side. more in those cases where partial cauterization Subsequent examination of the patient the next or enucleation is attempted than in cases where day showed the swelling to be more boggy and complete cauterization of adhesion has been painful. done, Aug., 19501 CUTANEOUS AMEBIASIS : GHOSH AND MUKHERJI 339

Occurrence of empyema necessitatis at the site of the puncture wound was due to the failure of the puncture wound tract to heal completely though superficially it was closed. The various predisposing factors which prevented the tract to heal from inside were :? (1) Infection of the tract from within the pleural cavity due to occurrence of empyema. (2) Excessive and troublesome cough, which interfered with the healing of the wound. Though for the complete closure of the tract the application of deep stitches has been recom- mended by some, in actual practice it is difficult to stitch the intercostal muscles. Later on thoracoplasty was done in this case for positive sputum, a big cavity which could not. be seen because of associated empyema, pleurocutaneous sinus and the empyema space.

My thanks are clue to Dr. T. J. Joseph, Medical Superintendent, Lady Linlithgow Sanatorium, for going through the case report and allowing me to send it for publication.