Thoracic empyema remains a major clinical con­cern. In addition to the classic parapneumonic empyema developing in the debilitated, elderly, or substance-abuse patient, new risk groups include patients undergoing high-dose chemotherapy, those who are immunosuppressed following transplantation, or individuals who experience AIDS-related compli­cations. Recent publications underscore the severity of this condition, reporting empyema-associated mor­tality as high as 20 percent.

Empyema is not a new problem. Treatment per­formed by the Sumerian asu (physician) was first described in the archives of Assurbinipal, the last great king of Assyria. Incision and drainage was deemed appropriate therapy for empyema necessitatis, which was undoubtedly due to a parapneumonic process in those days. It is interesting to note, however, that conservative measures were more the norm in Mesopotamian civilization. In fact, the Code of Ham­murabi (1700 вс) stated that the physician was not to be held responsible for the outcome of these infectious processes unless he chose to employ his knife for their drainage. Given the severity of some penalties for which the asu was at risk in case of misdiagnosis or misadventure during treatment (loss of a hand), it is likely that the asu strongly favored noninvasive therapy except in situations in which the diagnosis was obvious.

During the 4th century ВС, Greek physicians (IotTpos) had advanced the techniques of managing empyema to include early diagnosis, drainage, irriga­tion, and placement of an indwelling tube, as explained in detail in the Hippocratic treatise, On Internal Diseases. The evolution of these therapies is outlined in glorious detail by Guido Majno in The Healing Hand: Man and Wound in the Ancient World (Harvard University Press, 1975), which is fascinating reading for those interested in the history of medicine.
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The ancient Greek techniques for management of empyema became the standard of care for over two millennia. Only with the introduction of basic anes­thetic techniques permitting routine survival following open thoracotomy could there occur the introduction of surgical techniques used to manage complications of both bacterial and tuberculous pulmonary infec­tions. Thoracic surgery marked its zenith during the heyday of operative intervention for tuberculosis in the 1930s and 1940s. The introduction of sulfonamides in 1938, streptomycin in 1943, para-amino salicylic acid in 1946, and isoniazid in 1952 led to the gradual decline in surgical therapy for infections, beginning in the middle of this century.