Empyema commission of 1918—Impact on acute care surgery 100 years later

Abstract

H ippocrates (born circa 460 BC) first described the disease of empyema in ancient Greece. He detailed a technique for open drainage of chest. The Greek anatomist and physician Erasistrasus (born 304 BC) recognized the diaphragm was for breathing. Four hundred years later, another Greek physician, Galen (born 120 AD)made the discovery that intercostal muscles were also important for respiration. Nonetheless, advancements in our understanding of chest physiology and germ theory would not be defined and/or accepted for some time. As a result, mortality associated with this condition was nearly universal. It took more than two millennia, post ancient Greek civilization, before the first advancements in the treatment of empyema lead to improved survival. In 1844, two surgeons independently came up with the concept of repeated aspiration of the chest—Dr. Roe in Britain and Dr. Stokes in Ireland. German physicians in the 19th century were the first to described closed drainage thoracostomy systems for the chest (see Fig. 1). Empyemamanagement in the 19th and early 20th centuries was characterized by early surgical treatment by thoracotomy, extensive decortication with marsupialized external drainage (i.e., the Eloesser flap). Antibiotic irrigation would often be used as well. Perioperative morbidity and mortality—though improved from earlier times—remained unacceptably high. It is in this setting that the US military was beset by an epidemic of this disease among its World War I era personnel both within the United States and abroad. The lethality of this disease and variation in management among military surgeons led to the formation of a commission to study empyema care and create a set of recommendations for standardized management. The Empyema Commission was created in 1917 and published their initial results in the Journal of the AmericanMedical Association in August of 1918.Management of pneumonia and empyema was primarily through supportive care as antibiotics were not available. The collective understanding of chest physiology was also limited. Though the concepts of pneumothorax and negative intrapleural pressure were common knowledge, their importance was not appreciated and was a topic of significant debate in surgery. The majority felt that operating on one chest cavity led a single lung to collapse, leaving the mediastinum and the contralateral lung unaffected; however, many