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Treatment of Empyema
CENTENNIAL PERSPECTIVES
Treatment of Empyema C Barber Mueller, MD, FACS Hamilton, ON The 1923 Clinical Congress of the American College of Surgeons gave Evarts Graham 12 minutes to present is ideas on the treatment of empyema. Although a tall order, he did manage to restate and justify his three basic points: delayed open drainage, irrigation and sterilization of the cavity, and maintenance of nutrition. The bulk of his discourse was concerned with the principle of delayed open drainage; the consequences of an open pneumothorax, coupled with acute infection in the lung and a mobile mediastinum, were contentious issues not well understood. During 1917 and 1918, the most widespread and fatal epidemic of modern times ravaged the world; an estimated 500 million people contracted and 40 million died of swine-type influenza. After an attack of either measles or influenza, a form of pneumonia that had not been previously described was accompanied by a major loss of vital capacity and frequently followed by development of empyema thoracis. The pneumonic process was caused by the hemolytic Streptococcus and the subsequent empyema was very different from that previously seen after pneumococcal pneumonia. Surgeon General William Gorgas first established a Pneumonia Commission to study the pneumonia problem and followed it with an Empyema Commission stationed at Camp Lee, Virginia. Evarts Graham, a surgeon, and Edward K Dunham, a bacteriologist, were the first two appointed to the Empyema Commission. While serving, Graham prepared a major report on treatment of empyema, in which he showed that delayed open drainage was the best treatment. It was far superior to early open thoracotomy because of the effects of a pneumothorax that became superimposed on the respiratory embarrassment occasioned by acute pneumonia. He and Richard K Bell were then sent to Johns Hopkins to study the problem in animals and, while there, they described the physiologic consequences of an open pneumothorax. Their salient observation was that the mediastinum was mobile and compromised pulmonary function on one side and was matched by compromised
© 2005 by the American College of Surgeons Published by Elsevier Inc.
function on the opposite side. Simultaneously, Alexis Carrell found that irrigation with a hypochlorite solution (Dakin’s) would sterilize an empyema cavity, and a later report from Camp Lee documented the major deterioration in nutrition that occurred with pneumonia and its accompanying rapid respirations. The epidemic subsided almost as rapidly as it had begun. By 1923, a surgical entrance into the thoracic cavity was beginning to occur, with most of the clinical experience obtained from young individuals (wounded soldiers) or from patients with chronic infections (chiefly tuberculosis). Many prominent surgeons, among them Berkley Moynihan of Great Britain and Pierre Duval of France, believed that an open thorax was no more hazardous or lethal than an open abdomen, and the most highly debated issue became that of mediastinal mobility, something counter to conventional wisdom, which believed the mediastinum was a fixed, immobile structure. By virtue of his experience with the Empyema Commission, Evarts Graham had become a world expert on open pneumothorax in surgical management of empyema, and he believed strongly that all should know the underlying principles. During the decade of the 1920s, many of Graham’s publications and speeches were concerned with the physiology and consequences of open pneumothorax and, in May 1923, he made a major presentation to the American Association for Thoracic Surgery, in which he discussed open pneumothorax and its consequences. His presentation to the ACS Clinical Congress in October, to a wider and more general audience, summarized the principles that he had reported to the thoracic surgeons. Graham’s successful pneumonectomy was yet to happen, and thoracic surgery was only for the strong and daring, but he must have sensed that an understanding of the pulmonary and vascular responses to an opening in the chest was essential to the upcoming development of thoracic surgery. In a classic confrontation between laboratory research
158
ISSN 1072-7515/05/$30.00 doi:10.1016/j.jamcollsurg.2005.02.009
Vol. 201, No. 2, August 2005
findings and clinical experience, Graham stubbornly defended the conclusions that he and Bell had drawn from their laboratory experiments (which turned out to be correct), overturning impressions gained from clinical observations. It was a struggle that foreshadowed a conflict that occurred during World War II when Frank Meleney’s observations on the lack of benefit with use of local sulfanilamide in wounds was opposed to the clini-
Mueller
Treatment of Empyema
159
cal observations of IS Ravdin in Burma and the surgeons at Pearl Harbor. As the decade passed, Graham’s ideas and physiologic principles were gradually adopted. Intrathoracic surgery gradually changed from that of treatment of infections to treatment of malignancies, and Evarts Graham gradually changed from being a general surgeon to a worldrenowned thoracic surgeon.
Treatment of Empyema C Barber Mueller, MD, FACS Hamilton, ON The 1923 Clinical Congress of the American College of Surgeons gave Evarts Graham 12 minutes to present is ideas on the treatment of empyema. Although a tall order, he did manage to restate and justify his three basic points: delayed open drainage, irrigation and sterilization of the cavity, and maintenance of nutrition. The bulk of his discourse was concerned with the principle of delayed open drainage; the consequences of an open pneumothorax, coupled with acute infection in the lung and a mobile mediastinum, were contentious issues not well understood. During 1917 and 1918, the most widespread and fatal epidemic of modern times ravaged the world; an estimated 500 million people contracted and 40 million died of swine-type influenza. After an attack of either measles or influenza, a form of pneumonia that had not been previously described was accompanied by a major loss of vital capacity and frequently followed by development of empyema thoracis. The pneumonic process was caused by the hemolytic Streptococcus and the subsequent empyema was very different from that previously seen after pneumococcal pneumonia. Surgeon General William Gorgas first established a Pneumonia Commission to study the pneumonia problem and followed it with an Empyema Commission stationed at Camp Lee, Virginia. Evarts Graham, a surgeon, and Edward K Dunham, a bacteriologist, were the first two appointed to the Empyema Commission. While serving, Graham prepared a major report on treatment of empyema, in which he showed that delayed open drainage was the best treatment. It was far superior to early open thoracotomy because of the effects of a pneumothorax that became superimposed on the respiratory embarrassment occasioned by acute pneumonia. He and Richard K Bell were then sent to Johns Hopkins to study the problem in animals and, while there, they described the physiologic consequences of an open pneumothorax. Their salient observation was that the mediastinum was mobile and compromised pulmonary function on one side and was matched by compromised
© 2005 by the American College of Surgeons Published by Elsevier Inc.
function on the opposite side. Simultaneously, Alexis Carrell found that irrigation with a hypochlorite solution (Dakin’s) would sterilize an empyema cavity, and a later report from Camp Lee documented the major deterioration in nutrition that occurred with pneumonia and its accompanying rapid respirations. The epidemic subsided almost as rapidly as it had begun. By 1923, a surgical entrance into the thoracic cavity was beginning to occur, with most of the clinical experience obtained from young individuals (wounded soldiers) or from patients with chronic infections (chiefly tuberculosis). Many prominent surgeons, among them Berkley Moynihan of Great Britain and Pierre Duval of France, believed that an open thorax was no more hazardous or lethal than an open abdomen, and the most highly debated issue became that of mediastinal mobility, something counter to conventional wisdom, which believed the mediastinum was a fixed, immobile structure. By virtue of his experience with the Empyema Commission, Evarts Graham had become a world expert on open pneumothorax in surgical management of empyema, and he believed strongly that all should know the underlying principles. During the decade of the 1920s, many of Graham’s publications and speeches were concerned with the physiology and consequences of open pneumothorax and, in May 1923, he made a major presentation to the American Association for Thoracic Surgery, in which he discussed open pneumothorax and its consequences. His presentation to the ACS Clinical Congress in October, to a wider and more general audience, summarized the principles that he had reported to the thoracic surgeons. Graham’s successful pneumonectomy was yet to happen, and thoracic surgery was only for the strong and daring, but he must have sensed that an understanding of the pulmonary and vascular responses to an opening in the chest was essential to the upcoming development of thoracic surgery. In a classic confrontation between laboratory research
158
ISSN 1072-7515/05/$30.00 doi:10.1016/j.jamcollsurg.2005.02.009
Vol. 201, No. 2, August 2005
findings and clinical experience, Graham stubbornly defended the conclusions that he and Bell had drawn from their laboratory experiments (which turned out to be correct), overturning impressions gained from clinical observations. It was a struggle that foreshadowed a conflict that occurred during World War II when Frank Meleney’s observations on the lack of benefit with use of local sulfanilamide in wounds was opposed to the clini-
Mueller
Treatment of Empyema
159
cal observations of IS Ravdin in Burma and the surgeons at Pearl Harbor. As the decade passed, Graham’s ideas and physiologic principles were gradually adopted. Intrathoracic surgery gradually changed from that of treatment of infections to treatment of malignancies, and Evarts Graham gradually changed from being a general surgeon to a worldrenowned thoracic surgeon.