CASES OF EMPYEMA AT CAMP LEE, VA

EDWARD K. DUNHAM, EVARTS A. GRAHAM, JAMES F. MITCHELL, ALEXIS V. MOSCHCOWITZ, RALPH A. KINSELLA, RICHARD D. BELL, FRANKLIN A. STEVENS, WILLIAM L. TOWER, CLIFFORD C. HARTMAN, THOMAS M. RIVERS, FREDERICK D. ZEMAN, MILTON B. COHEN (+3 others)
1918 Journal of the American Medical Association  
The pleural exudates from the cases at Camp Lee were examined both in smears and' plate cultures prepared with plain agar to which 10 per cent, of defibrinated human blood had been added. In the fluids obtained by aspiration, hemolytic st r e[ i l l ]tococci alone were found. These were often extremely abundant, a single loop of the exudate yielding from 100,000 to 200,000 colonies in plate cultures. Stained smears from these exudates showed that the majority of the leukocytes present had
more » ... s present had undergone necrosis and were in process of disintegration. In many cases there was no evidence of phagocytosis. In other, but fewer, cases, phagocytosis was very marked; as many as forty cocci, sometimes in threads of considerable length, more often appearing as diplococci, were seen in a single phagocyte. But there were always more free organisms than the number incorporated, and the phagocytosis never appeared to be a decisive feature. When it occurred the organisms within the phagocytes sometimes failed to stain deeply and occasionally were reduced to mere shadows, but rather more frequently it was the phagocyte that gave evidence of retrograde changes. In one case, however, the exúdate was found to be sterile after the pleural cavity had been several times aspirated, and it is possible that phagocytosis may have been the determining factor in bringing about this result. The arrangement of the cocci as seen in smears was sometimes in pairs, but short chains'of from four to eight biscuit-shaped diplococci were of more frequent occurrence. Longer threads of eighty or more such individuals were rare, but in cases in which these were present, they were often as abundant as the shorter chains. No definite relation could be observed between the severity of the cases and those differences in the streptococci. The progress of disinfection was followed in the majority of cases coming under the care of the com-mission, by means of both smears and cultures from the discharges. When practicable, this was regularly done twice weekly in each case. The results of these studies are of considerable interest, for they demonstrate that the hemolytic streptococcus may persist for a long time in cavities that are merely allowed to drain without affective antiseptic treatment. In one case this organism was continuously present over a period of nearly six months. They also emphasize the importance of free drainage. Where this is not provided, antiseptic treatment that would otherwise, in the light of observations in freely draining cases, prove effective has failed to accomplish disinfection. It appears to be a legitimate conclusion from the experience gained through the systematic bactériologie control of the treatment that when little or no progressive diminution in the numbers of streptococci follows treatment, there must be conditions in the cavity either impeding drainage or preventing contact of the antiseptic solution with all parts requiring disinfection. The value of this information in deciding on modifications in treatment is obvious. The hemolytic streptococcus is by no means the first organism to disappear under antiseptic treatment in mixed infections of cavities neglected after operation. Putrefactive organisms and the Bacillus pyocyaneus disappear much eariler than the streptococcus, as determined by plate cultures. In general, it was observed that the hemolytic streptococcus was present Up to the time that the total number of colork-s developing from a loopful of secretion fell below 100. When the secretion from the cavity itself became Very scanty, it was often impossible to obtain this standard quantity of representative material for culture. If, at that time, a sample of the secretion from the wall of the sinus was taken, this almost invariably contained a large number of viable organisms; but the hemolytic streptococcus could usually no longer be detected even in this situation. In the routine of dressing adopted, the sinus was bathed with antiseptic only when the dressings were renewed and a culture from this situation obtained only at the longest interval after irrigation. The presence here of large numbers of organisms is, therefore, to be expected. The observations cited show, however, the importance of disinfecting the sinus when the cavity has reached a satisfactory stage of cleansing. For this purpose, a daily treatment with dichloramin-T appears appropriate ; but other means might prove equally effective. Until the lung has fully expanded and the wound closed, both cavity and sinus are favorable sites for reinfection. The curves in Figure 3 illustrate the progress in four recent cases with operation in which disinfection proceeded favorably.
doi:10.1001/jama.1918.26020320003010 fatcat:hbcmdgczwbf2receo3g6xfkwsu