Back to Founding of AATS
During the 20 years prior to Founding of the Association, no subject
was discussed as freely or as vehemently in medical literature as empyema.
Differences of opinion were multitudinous, far exceeding those in any other
area. One prospective AATS member disapproved of the Founding with the
objection that once empyema was covered, the Association would dry up for lack
of topics.
Many Founders contributed frequently to the acrimonious debate.
Prominent among them were Lilienthal, Robinson, Von Eberts, Kenyon, Ware,
Wilenski, Green, Carrel, Hartwell, Janeway, Lambert, Heuer, and Scudder.
In the early days of the concentrated attack on thisentity, primary
emphasis was on the importance of the infection. Removal of the infected
pleural fluid was considered necessary. Repeated needle aspiration,
intermittent aspiration through a tube, simple drainage, wide thoracotomy with
and without rib resection, positive and negative pressure and other methods,
all had avid supporters. No group could report uniform success, and death and
chronic empyema were common aftermaths.
A reading of the record impresses one with the lack of attention to the
one factor which in other situations was given primary consideration. The
hazard of open surgical pneumothorax and appreciation of the necessity for its
avoidance had, in fact, sparked the effort which evolved through intratracheal
insufflation to our present endotracheal technique. Yet in the area of empyema,
it received only scanty and occasional consideration. The nicely walled-off
pleural abscess was not differentiated from acute suppurative pleurisy without
adhesions. Discussion lumped them together with regard to therapy. Results
obtained with open drainage of-the pleural abscess were sufficiently good to
prompt many to advocate its use in all cases. Ensuing deaths or poor results in
the form of chronic empyema after such operations were, on the other hand,
construed by some as sufficient grounds for abandoning the method in favor of
aspiration or exploration and closure without drainage. When thoracotomy was
applied to the acute form, either disaster or poor results were the rule.
Temporary or permanent fixation of the lung to avoid "mediastinal flutter" was
used by some hardy enthusiasts while others advocated either continued negative
or positive pressure. With any method, the results were usually discouraging.
Experiences during the early days of World War I illustrate the
situation. In 1917 Col. Gray summarized the early British experience in a
symposium on chest injuries.1 It is surprising to note that while
exploration, debridement, washing the pleura, lung repair, and the like were
considered acceptable, the chest still had to be closed tightly without
drainage. It was stated that drainage was the cause of post-operative infection
and of practically all the poor results. Such attitudes prevailed widely, which
is quite amazing since medical literature did contain reports on methods which
might have remedied the situation. Methods to maintain both lung expansion and
function and reduce the residual pleural space had been reported as early as
1873. Only by 1903 did a new awareness begin to prevail. Many Founders
contributed. In 1910, Robinson screwed a metallic tube into a trephine hole in
a rib.2 In 1911, Von Eberts used multiple cuffs, paste rubber
sheeting and adhesive.3 Lilienthal employed either a tube with a
soft rubber valve or provided suction by using a home vacuum cleaner.4
Kenyon in 1916, made the most meritorious contribution when he reported an
airtight, underwater drainage system which he had used successfully in
controlling a traumatic hemopneumothorax on May 23, 1913. This significant
observation did not receive its due until some years later, although its
soundness is attested by its common use today.
Robinson - rib
trephine for airtight thoracic drainage.
Von Eberts' cuffed
tube for airtight pleural drainage.
Kenyon - airtight
underwater drainage.
Carrel - War
Demonstration Hospital where the Carrel-Dakin treatment was taught.
Carrel in French
uniform, with Dakin to his right, and a class of American Officers.
As the world situation continued to deteroriate, culminating in
American declaration of war on April 6, 1917, medical leaders became concerned
about our relative inexperience with thoracic problems of war. A logical step
was to take advantage of the experiences of our Allies. Since empyema was a
most pressing problem, the aid of Dr. Alexis Carrel was solicited. While the
Carrel-Dakin method brought about some improvement in results, it was not the
complete answer. Chronic empyema was still far too common.
The faults of collapse operations to close the empyema were
appreciated. They were long, bloody procedures with a significant mortality,
and were, at best, severely disfiguring - many considered them mutilating. They
often entailed a loss of physiological functional capacity inconsistent with a
productive life. They were not applicable to bilateral disease. Many Founders
realized that re-expansion of the trapped lung was preferable.
Decortication, introduced by De Lorme and Fowler in 1893 and modified
to gridironing by Ransohoff in 1906, was advocated cautiously. Notable
followers of this approach were Lilienthal and Heuer. It is surprising to note
that even after successful decortication, closure of the chest without drainage
was often . recommended. It is even more surprising to learn that many
excellent results were obtained with the method in spite of this serious error.
It was not until some years after the Founding that empyema, the most
pressing problem in pleural surgery, finally came under maximal control by
applying all the principles which actually had been known through the years.
