FCREWORJ 
Persistent cavities (Resthoehle) in the chest 
have taxed the skill of surgeons since the early 
days of chest surgery. It is unusual for any one 
sura on to have an extended series of these cases, 
Bernhard has reported here the results obtained 
by using HELLER *s Lattice Plastic operation. 100 
of the cases followed empyema and 24 of them followed 
hemothorax. They include cases of fairly recent 
origin and older cases, even one of 25 years 
duration. 
It is unfortunate that all the original 
illustrations could not be reproduced. However, 
the loss of X-ray films by fire and water damage, 
hasty removals and temporary storage incident t• 
developments during the war are completely under- 
standable , 
The experience recorded in these two articles 
has been enlarged since they were written with 
eoually successful results. 
HARRI J, ALVIS 
Commander, Medical Corps 
U, S. Navy Surgical Clinic of the University of Giessen 
Director: Prof, Dr, BERNHARD 
THE RESIDUAL CAVITY OF THE HEMOTHORAX 
by 
Prof. Dr. Fr, BERNHARD 
With 1+ Illustrations 
1r anslation prepared by: 
U, S, Naval Technical Unit, Europe, (Medical Section) 
Office of Naval Adviser 
Office of Military Government (U, S,) 1 
During the first World War, special interest 
was paid to penetrating gunshot wounds of the chest. 
Based on the fundamental works if SAUFRBRUCH concern- 
ing thoracic surgery, considerable improvement in 
the treatment of this serious injury was obtained, 
and general instructions for the treatment were establish- 
ed whidh are still correct. This is also the case with 
the hemothorax which is rather regularly associated 
therewith in various degrees. Concerning this clinical 
picture, in the first years of the World War I, the 
necessity of removing each accumulation »f blood in the 
thorax by repeated punctures in order to avoid serious 
complications, even when it did not cause any immediate 
threat to life by displacement phenomina, was observed 
too infrequently. The earlier apprehension concerning 
this treatment proved to be unfounded. Hitherto, the 
treatment of the hemethorax was improperly considered 
to be concluded with the relief of the immediate danger 
and no longer to be the subject of medical treatment 
or surgical action. is a consequence the possible 
formation of thick callus in the pleural space has been 
observed. During World War I, it was established 
by MORITZ, when he summarized numerous gunshot wounds 
of the chest, that the final result of the hemorrhage 
into the pleural cavity were unsatisfactory, and that 
scars and wheals could be the cause of considerable 
and manifold pains with a great number of soldiers. By 
careful examination he came to the astonishing con- 
clusion that pleuraempyemas show a better prognosis 
after the surgical drainage of the pus chan the non- 
treated and non-infected hemothoraces, With chis 
statement one was content. An explanation of this 
contradictory circumstance did not occur. Therefore, 
the way could not be found by which better results 
could be obtained with the hemothorax. 
From my exoeriences, the cause of the unsatis- 
factory results is to be seen with the subsequent con- 
ditions of numerous penetrating injuries of tne chest 
in a hithertp_un£bseryed_clj_nical_picturthe causes 
of which have been known for a long time. With more 
than 20 wounded soldiers I was able to prove by X-rays 
as well as by operative findings, that in spite of 
previous repeated puncture, astonishingly large cavities 
are often hidden in the so called "callosities11 follow- 
ing an effusion of blood into the thoracic cavity, 
(in, i). 
This residual_cayitx_f»11nwing_a_hemothorax is 
almost regularly filled with thick clumps of old remnants 
of fibrin. It contains only a little brownish liruid 
and consequently escapes diagnosis by the simple test 
puncture. The wall consists of wheals of several 
centimeters of thickness, and is covered with old and 
decaying layers of fibrin. The clinical picture can be 
considered as a result of the pleuritis wh?ch occurs 
after hemorrhages into the pleural cavity. On 
account of the chronic processes of inflammation and 
the phenomena of disintegration (decay) in the old 
fibrin clumps, toxic albuminous substances enter the 
circulatory system and cause noticeable abnormal varia- 
tions which continue for a long time. They cannot be 
4514 4 G Is - 
Illustration 1 
Big, coatlike callus, one year after injury through 
shell splinter, with additional hemothorax, A big 
hemothorax residual cavity has been found and closed 
by thoracoplasty, 
a) Condition before the plastic, 
b) X-ray after plastic gives an imagination of 
the extension of the cavity. 2 
removed by medical hospital treatment even this ex- 
tended for a long time. Only by an active procedure 
or surgical treatment was success achieved in saving 
such soldiers from a chr&nic disability and to obtain 
either a healing #r a complete fitness for military 
service * 
I therefore consider it my duty to call attention 
to this as beet of disease and to point out its jsymp- 
toms. For this purpose I will not give a detailed re- 
production of the numerous hospital reports since the 
observations correspond to each other with a certain 
monotony, I consider it most impressive to describe 
only the first observation with wh?«h I found, by 
chance a great cavity in the pleura after an earlier 
hemothorax, in order to give in connection thenewith 
a survey of my clinical experiences with the residual 
cavity of the hemothorax. 
The 23 year #ld soldier had been wounded by 
a small arms projectile on September 21, 194-2, and 
received a gunshot wound with the missile passing 
through the right lung, A hemothorax developed which 
was aspirated several times. At first there were 
great quantities of a sanguinous fluid. The punc- 
tures undertaken later on were negative. On January 
15, 194-3 he was received in a specail hospital for 
patients suffering from injuries of the lungs,. Con- 
trary .to similary wounded men, he did not recover in 
spite of the same treatment. His general condition 
left much to be desired. His appetite was moderate. 
He always felt faint and physically weak, He was not 
even able to tolerate light physical exertions. In 
addition to a shift to the left, the blood cell count 
sho?/ed a slight anemia. The sedimentation rate was al- 
ways slightly accelerated. The right half of the 
thorax showed a distinct shrinking, and the inter- 
costal spaces showed considerable limitation, Clinical- 
ly and radiographically an extensive thickening of the 
pleura was found. Repeated punctures again showed 
negative results. However, based on my other ex- 
periences with sequelae of gunshot wounds in the lungs, 
I supposed a focal inflammation in the thickened pleura 
was to be considered the source of infection . The 
general condition was similar to that of focal infection. 
With regard to this I recommend a diagnostic thoraco- 
tomy which the attending physician agreed to since he 
was not successful with medical treatment, and the 
patient also consented because of feeling sick without 
any recognizable cause and wishing to get rid of it all. 
On August 9, 1943, I operated above the middle of 
the thickened pleura under local anaesthesia performing 
an extended subperiosteal resection of the right sixth 
rib. The exposed periosteum and the considerably 
thickened pleura, lying below it, was split along the 
course of the rib. After separating a callius of more 
than 3 centimeter thickness I opened into a cavity which 
circumscribed nearly the entire right half of the pleural 
cavity. It contained air and only a small quantity of a 
turbid, slightly bloody fluid in which a non hemolyzirig 3 
accumulation cocci could be demonstrated bacterio- 
logically. Besides there were decaying, bad 
smelling clots of fibrin larger- than a fist. Re- 
siduals of the earlier hemorrhage were indicated by 
their yellowish color as well as the pleural callus-. 
The wall of the cavity was covered by similar, not 
very adherent layers which were curretted away. After 
the cleaning of the cavity, it was closed according 
to the principle of the lattice plastic operation by 
HELLER, (The lattice plastic is a method of thoraco- 
plasty which was described by HELLER in 1934#) There- 
with in the thorax above the cavity, which must be closed, 
the ribs are subperiosteally excised and then the 
periosteum is split in the middle along the course of 
the ribs and likewise the thickening of the pleura lying 
underneath the ribs. By this way the intercostal nerves 
and vessels remain intact. Strong ligaments of soft 
parts develop from the intercostal muscular apparatus 
and the thickening of the pleura. They can be made 
movable and when the technioue is correct, they hang 
down slackly so that astonishingly large and deep 
cavities can easily be eliminated, I applied this method 
in nearly 150 cases of empyema residual cavities and 
was successful in closing each cavity by this excellent 
operation, no matter how difficult the situation of the 
cavity may have been. The lattice plastic operation 
reouirad an extended subperiosteal resection of the 
second to nirith rib* The postoperative course was smooth, 
and 4 weeks later the discharge to the special hospital 
for after treatment of the gunshot wounds of the lungs 
could take place for convalescence. 
The result of the operation was astonishing. After 
removing the residual cavity of the hemothorax with 
its decomposing mass of albuminous matter, all the 
phenomena of disease, previously present; disappeared. 
The appetite returned and caused a considerable increase 
of weight which previously had not loe.i obtained in spite 
of all efforts. The general weakness ana fatigue dis- 
appeared. The wounded man ar,ain felt like a healthy 
man. The functional capability improved. The blood 
picture and the sedimentation rate returned to normal. 
The impairment of the respiration which was caused by 
the elimination of the entire right lobe of tha lungfnatural- 
ly could not be avoided. The general condition progressed 
so satisfactorily that, after a short time of convales- 
cence, the patient could be released from the hospital 
whereas before the operation the disease could not be 
influenced by any means, not even by excellent medical 
management for a period of 7 months. 
The course of this observation described in de- 
tail gave a very imporessive idea of the clinical impor- 
tance of the residaul cavity of the hemothorax. After 
this description, the most important viewpoints brought 
along with the aspect of disease and the ouestions 
started by it can be discussed more easily and under- 
stood with a further 23 cases on the basis of this ex- 
perience , 4 
First of all we have to consider the cause. With- 
out doubt this is to be seen in the so called post- 
hemorrhagic pleuritis. The residual cavity of the 
hemothorax represents an aftermath of this condition. 
This explanation is not sufficient in regard to the 
evaluation of this aspect of the disease. On the 
contrary we must consider in detail tbs ouestion - why the 
presence of blood in the pleural space causes a serous 
exudate of the pleura which sometimes requires frequent 
aspiration and discharges considerable quantities of fluid 
after what primarily was not too severe a hemothorax. 
Concerning this there exist two different con- 
septions, MORITZ considers the cause for the post- 
hemorrhagic pleuritis to be a simultaneously occuring 
infection. doubts the correctness of this 
opinion with the justified objection that the hemorrhage 
generally is found to be sterile. His opinion is that 
the entire process is based on an aseptic inflammation 
and formation of exudate. With this interpretation 
the question is left undecided as to why with some 
people only the pleura is susceptible to the irritation 
of the extravasation and causes an abundant exudation of 
fibirn and a marked pleural thickening. 
A short consideration of this problem is not to be 
avoided since the cause of the posthemorrhagic pleuritis 
is of decisive importance for the treatment of the re- 
sidual cavity of the hemothorax. From bhe last - orld 
War there are some investigations on the behaviour of the 
hemorrhage with penetrating gunshot wounds in the chest 
(REHN, COBFT, TOFNISSEN, GFRHARDT and others'. 
According to experiments on animals, an accumulation 
of blood in the pleural space should not leave behind any 
sequelae. With horses, TROUSSEAU has brought into the 
pleural space great quantities of blood. This was ab - 
sorbed with astonishing speed and completely without 
donseouences. MORITZ, repeated these experiments with 
dogs and found the same result, Fvom these observations 
and his clinical experiences he concluded that hemothorax 
in man was a harmless matter which did not lead to a 
posthemorrhagic pleuritis if it is truely sterile. He 
points out to the numerous hemorrhages which were so 
frequent during the war with wounded soldiers and which 
were rapdily absorbed without leaving benind bad se- 
quelae, as there are thickenings and callus. Wow this 
would be the normal course with a sterile hemothorax. The 
frequently ne-ativo bacteriological examination in the 
hemorrhages which are not absorbed represents an im- 
portant objection. MORITZ opposes the same with the 
following evidence; The question concerns attenuated 
agents or the conseouences of their toxins. The presence 
of highly virulent germs on the contrary should lead to 
a pleural empyema. 
Our own observations contain several viewpoints 
which are important in reply to this formulation of the 
question. First of all, the result of the bacteriological 
jJ3X§sii.gaii.aaj ia interesting. With the larve number of 
the patients who had passed through many hands, the ab- 5 
sence of a systematic bacteriological examination is 
not surprising. Conseouently, a tabular summary cannot 
be given. Therefore, I wish to restrict this discussion 
to a short summary of the results. From the 24 residual 
cavities of hemothorax which I have seen until now, 
I have operated 18, Before the operation a search for 
pus forming germs took place only in the fluids obtained 
trr puncturing 7 wounded men. With more than half of 
them (4)9 staphylococci and streptococci were, some- 
times repeatedly, demonstrated. With the thoracoplasties 
we searched for bacteria in the fluid of most of the 
cases. Among 14 specimen, bacteria were found in 7 cases, 
which had been established with some wounded men even 
before the operation. Success was achieved in healing six 
further residual cavities of the hemothorax without 
operation, but only by the negative pressure treatment* 
In all these cases the search for pus forming bacteria 
was negative though it was repeated several times. 
For this there are two possible explanations. uince 
this aspect of disease could be healed without operation, 
the disease was probably less severe than with the cases 
treated by a thoracoplasty. Furthermore, the possibility 
must be considered that during the existence of the re- 
sidual cavity of the hemothorax for months and years the 
germs have been destroyed. In this sense the negative 
bacteriological findings in fluid obtained by aspiration 
from wounded men can be explainsd in whom at an earlier 
date, when the hemothorax was not so old, bacteria might 
have been found, Adir ttedly, these findings do not 
permit a definite conclusion on the cauf3 of the hemorrhagic 
pleuritis, but on the other hand, there is no doubt, after 
these bacteriological results, that the infection has a 
decisive influence on the development of the residual 
cavity of the hemothorax following a penetrating gun- 
shot wound in the chest. 
Further important observations can be cited to 
support this interpretation. With the microscopic 
examination of the fluid obtained by puncture. The 
presence of many leucocytes was astonishing. With some 
residual cavities there were even fluid transitions to the 
pleural empyema. As to the surgical findings, three 
wounded men showed a closed empyema residual cavit}?-, 
when the clinical course and the development of a hemo- 
thorax existing for many months would net nave suggested 
placing them in the group having a residual cavity of the 
hemothorax. Also the thick clumps which were regularly 
found in these cavities at the thoracoplasty, are worth 
mentioning for they showed rather the same structure as 
those of the same sort which can be found after a short 
time with every infected pleural empyema. 
Finally the symptoms of disease, whrch are to be 
described in detail, have to be taken into consideration. 
They can be explained in the most convincing manner 
by the presence of a bacterial infection. Their dis- 
appearance after removing the focus of the disease is to 
be considered as a direct pro*f. All these view points, 
however, suggest making the penetration of germs re- 
sponsible for the development of the residual cavity of 6 
the hemothorax with a probability that is nearly cer- 
tain, How far this conseauence can be applied to the 
posthemorrhagic pleuritis, can be passed over here. On 
the other hand, from this knowledge and the principles of 
general surgery the postulate can be formulated 
indicating the surgical treatment of each residual 
cavity of the hemothorax as soon as it causes pains 
and its healing cannot be obtained by other methods, 
in order to remove the focus of inflammation and its 
seouelae from the body* 
A reproduction in detail of our £athpltgic#-anatpm- 
is, not necessary. But some short re- 
marks for the better understanding of the whole ex- 
planation cannlt be avoided. Similar to residual cavities 
follwoing empyema, the cavity after a preceding hemothorax 
can occupy an entire half of the thorax or only a part 
of the same* The flhst form occurs rarely. The second 
appears nearly always in the post-rior lower part of the 
pleural cavity and has the shape of a cloak. There- 
fore, it is most practical to distinguish between a 
partial and a__total_residual..cavity of the hemothorax. 
The ¥\rall of the hollow space is formed by a thick callus 
which may be as thick as 5 centimeters. Usually it has 
a gray-white color, but sometimes it has a brownish- 
yellow tinge, and can contain residuals of the proceeding 
absorption of blood. The callus shows concentric layers. 
On their inside there aif* often layers like the layers of 
an onion. The content chiefly consists of air and ge- 
latinous, fibrinous clumps of fibrin. There cause a 
comprehensible astonishment. Sometime'3 t ere on the 
point of decomposition and have a oc.cr ■ &p on da ng color. 
Small ouantitjes of fluid may be prep out which can 
easily be overlooked during the puncture. Usually It 
has a brownish, sometimes a chocolate colored apoearnnee, 
The histological structure depends somewhat on the 
age of the callus... Sometimes the pleural thickening 
is composed of hyalinizing connective tissue, rich in 
vessels, w th fibrinous layers. On the other hand, it 
can als» be permeated by chronic inflam atory infiltrations 
and may contain cel1s containing hemosidering, Occasional- 
ly the wall next to the cavity is covered by granulation 
tissue or is infiltreated by "pus coruusc1esH so that it 
could be considered as the wall of an <mpyoma residual 
cavity. The microsctpic findings tccveforo point to a 
bacterial origin of the hemothorax cavity, 
The greatest interest is claimed by the clinical 
course- When reviewing the hospital reports, it was 
striking that most of the soldiers must have given the 
impression of a more severe illness than is usually 
the case with a hemothorax. Yet more important, how- 
ever, is the conseouent behaviour. Generally the wounded 
men recover weln from the consenuences of a penetrating 
gunshot wound in the chest with subservient hemothorax 
after some punctures. The thickening which remains at 
first, has the tendency to involution so that later on 
the pleura again becomes soft and pliable. This course 
is missed with soldiers who have a residual cavity of a 
hemothorax. Als# under the most favorable conditions and 7 
with the best care the convalescence takes place rather 
slowly or is even unsuccessful. 
The clinical picture is marked by the chronic 
intoxication from the focus of inflammation in the 
thorax. The thick indurated wall hinders a ouick ab- 
sorption and represents a mighty barrier against the 
bacteria, their toxins, and the decomposition products 
of the protein. This vie?/ point is important for the 
understanding of some peculiarities. For a great part 
it is t» be made responsible for the relatively varue 
general symptoms. The uatients complain of faintness, 
weariness and feebleness. Particularly younger wounded 
men are m»st impressed by their decreased physical 
efficiency as well as by the weakness occurring after a 
short walk. Most of them suffer from anorexia. The pains 
caused by lical changes are few. The shortness of breath 
seems to be considerably greater than after the usual 
penetrating gunshot wound in the chest. Its disappearance 
•r its improvement after the successful treatment of the 
residual cavity removes every doubt of the causal con- 
nection; 
The exam nation also offers so few obvious find- 
ings that overldoking the cavity is very well under - 
stood. The involved side always lags noticeably. The 
shrinkage of the same is the most pronounced sign and 
is best recognized by a comparison with the sound side. 
The extremely narrowed intercostal spaces and the ribs 
tightly pressed together signify th seriousness of the 
intra-thoracic shrinkage process, .. v as nearly always 
able to explain the fundamental complain be from the simple 
consideration with regard te the course. 
For the exact diagnosis.* a greater number of 
auxiliary means are available. Part of them belong proper- 
ly to the clinical course. Diagnosis is discussed, how- 
ever, in this section in order to avoid repetitions. 
The main point for the recognition seems to be that 
one is thinking of the presence of a residual civity 
of the hemothorax with the pains after a penetrating 
gunshot wound in the chest. It is suitable for the 
systematic discussion to separate r.' r general and the local 
symptoms. The first one has partly been mentioned aith 
the discussion of the clinical picture , low over, the 
behaviour of the body temperature has to be pointed out. 
When examining the temperature curves it is striking 
that the temperature is often at the upp r limit of the 
norm and sometimes may show transient considerable in- 
creases , 
Since the abnormal changes are caused by inflamma- 
tory processes, the behaviour of the bl&od picture has to 
be taken in consideration. The number *f the white blood 
corpuscles is generally normal. With a repeated examin- 
ation, however, slightly increased values are found,* 
Occasionally transitory pronounced leukocytosis appears. 
The sedimentation rate is n#t reliable, vven with tran- 
sitions to the pleura empyema, the acceleration »f 
the sedimentation rate is occasionally absent. Such a 
discrepancy can easily be the source of a faulty inter- 8 
pretation. Generally, however, a slightly increased 
acceleration of sedimentation rate can he observed. 
As with the whi te cell blood count a freouent repetition 
of the test is highly recommended here also. The 
occasional slight anemia is not useful since it is not 
only a conseauence of the chronic intoxication, but is 
a freouent finding in the first months after gunshot 
wounds in the lung. 
Even when all points of view indicate the presence 
of a residual cavity of the hemothorax, one has to 
endeavour to explain the diagnosis absolutely. The 
physical examination leads regularly to the assumption 
of a callus formation. This is confirmed by the re- 
sult of the survey X-ray of the lunr, Still greater 
errors occur when a large cavity contains much air and 
has no particularly thick wall. Only the presence of 
a sufficient quantity of liquid makes possible an 
accurate interpretation of the circumstances, but this 
often does not occur. Conseouently the clinical and the 
X-ray examination scarcely surpass the easy diagnosis 
based on thickened pleura formed aft t hemothorax. 
Also the test puncture fails in consequence of the 
peculiar aspects of disease. Its negative result is for 
the most part responsible for the ov rlooking of the 
residual cavity following hemothorax. By the observation 
of certain directions, however, success is achieved in re 
forming th s method of examination to t.Jie most infallible 
diagnostic auxiliary means. According or cur experiences 
the proceeding is simple and withoua danger. By means 
of a not too th:n puncturing needle one pierces the 
region of the greatest thickening and also at the favor- 
ite location of the residual cavity following hemothorax. 
If there is a hollow space below the callus , it can 
easily be rec»gnized. For, after overcoming the resist- 
ance in the thickening, the needle at once can be moved 
relatively easily. There one has the feeling of having 
reached an empty space, Nov/ is the piston of the 
syringe can easily be moved (to and fro) without the 
aspiration of fresh »r old blood, first of all some 
sterile sodium chloride solution is cautiously injected,. 
If this is very easy and can be followed with a larger 
quantity and without the occurrence of a ay phenomena of 
irritation, the presence of a rrlat.a« * ly large hollo-* 
space can be assumed, and the experiment of a contrast- 
demonstration may be undertaken. Greatest conscien- 
tiousness naturally is supptsed. In proceeding so we 
have easily fixed the size of the residual cavity of the 
hemothorax on the X-ray picture. 
Of course it must not be concealed that this reli- 
able and unobjectionable method leads us once into error. 
Probably the unusually numerous and thick fibrin coagula 
led to an obstruction of the puncturing needle. Since 
numerous phenomena of disease were present and all the 
other evidence indicated the presence of a residual 
cavity following hemothorax, I believed the under- 
taking of a thoracotomy to be in order. After the 
subperiosteal resection of a rib, I split the posterior t& - 
Illustration 2b 
could not be repro- 
duced with the facili- 
ties available. 
General radiography with 
callus, 
Contrast filling of the 
cavity, front view. 
Illustration 2 
c,d,e,f, 
Apparently unimportant formation of callus 1 
year after a machine pistol shot with subseouent 
hemothorax. The contrast medium proves the pre- 
sence of a large residual cavity which was closed 
very successfully by an operation. 
111. 2 
c 
Side-view picture of the 
cavity filled with the 
contrast medium* 8b. 
Illustration 2 
d 
General X-ray view after 
t horacoplasty. 
Picture of the thorax 
after the »peration, 
front view. 
Side-view of the same. Be 
General radiography of the 
lungs, 
Picture of the cav: ty after 
the injection of the con- 
trast agent. 
Illustration 3 
Extensive formation of callus after a small arm gun- 
shot passing through the left half of the chest with 
hemothorax residual cavity which can be proved by the 
injection «f a contrast medium and can be removed by 
thorac oplasty* 
Illustration U 
Radiography of a hemothorax 
residual cavity within a 
so-called callus after a 
gunshot wound with the 
missile in the chest. The 
light areas in the shadow 
are caused by fibrin clumps. 9 
ribperiosteura in its longitudinal direction and sub- 
secuently I cautiously opened the thick pleural callus, 
I reached into a typical residual cavity in which many 
old fibrinous clumps were found. With a cautious pro- 
ceeding there is no danger of a pleural opening or of other 
complications. With doubtful but suggestive clinical 
pictures, therefore, and considering the experience 
with the exploratory laparotomy in the case of vague 
abdominal diseases, the indication for a diagnostic tho- 
racotomy should be justified since not only the return 
of the fitness for military service, but also the 
health is endangered when the residual cavity following 
hemothorax is not removed. 
Thus we have to come to the treatment. It would be 
of some import anc e to know what the chances are of a 
spontaneous healing of such cavities, WEINER who,on 
the basis of postmortem appearances, saw the clinical 
picture for the first time in the year 1915 and believed 
it worth a description on account of its peculiarity 
doubted this possibility with a cavity the size only of 
a man’s fist and existing for nine months on the basis of 
his macroscopic and microscopic observations. I my- 
self would not deny it entirely* If, however, an 
inflammatory focus is present in the cavity which causes 
general phenomena of disease* I consider it must be 
clised in order ti regain the health and also the fitness 
fob military service. Naturally this should be obtained 
preferably by the redevelopment of +hs uings. Unfortun- 
ately this proceeding is limited by tha r. very thick 
pleural callus and frequently also by on- presence of an 
infection, Consecuently the thorac <. plasty cannot be 
avoided in the case when careful exercise continued for 
a long period has failed. Far this purpose the lattice 
plastic operation of HELLER is most suitable. Since this 
method does not show an alarming death-rate (among nearly 
100 empyema residual cavities which are to be considered 
as more severe, I lost only 3 soldiers by brain abscess) 
and does not leave any significant cosmetic deformity, 
contrary to the well-known plastic operation of SCHEDE 
too great a reserve towards the surgical action is not 
justified. 
In spite of allt* careful indi'at' "i j s suitable. 
The course of the first nine res’.or.s 1 c111 s of the 
hemothorax which I operated according to tnc ireohoi of 
HELLER were easy and smooth. After a few weeks they 
could be released. After the tenth and eleventh tho- 
racoplasty, however, in spite of having dusted sufficient 
Marfanil-Prontalbin pawder into the wound area, suppu- 
rations, which lasted for many weeks, appeared which 
transitorily endangered the general state of the elder 
of the two wounded men in a most severe manner, Both 
cases finally healed. The sorrow which they had caused, 
was, however, the reason to study again the possibilit}r of 
a less dangerous treatment. Therefore I undertook the 
experiment to reduce or to cl#se the residual cavity, 
b introducing a drainage tube and joining the same to 
the airpump operated by a jet of water. Favored by the 
old fibrin clumps and the residuals of the hemorrhage, a 
serious mixed infection occurred. As it was feared al- 
ready, an empyema residual cavity developed that had to 
be removed finally, after a leng and dangerous illness, 
b ■ a thoracoplasty. Thus valuable time had been lost and the wounded soldier had been brought into additional 
danger, 
Except for the suction drainage, the use of which 
is obvious at the present state of thorax surgery, I 
do not believe that it is right to report on all our 
tentative attempts. Perhaps it is most suitable to 
describe the proceeding which proved best in our case. 
With each residual cavity of the hemothorax we ascertain 
at first its capacity by means of the above described 
puncturing technioue injectioning a physiologic ■ saline 
solution. The liouid which is withdrawn is bacteriological- 
iy examined. The extent of the cavity should be established 
radiographically in the beginning of the treatment after 
the injection of a contrast medium, A?ter the rinsing 
of the intrathoracic cavity, we produce there a lower 
pressure »f such a degree that the patient complains 
of a disagreeable drawing or a feeling of pressure in 
the chest. Occasionally we made a trial of leaving negative 
pressure in the cavity, even up to 35 millimeters hemo- 
globin, After a week the same process has to be re- 
peated, since in this period the lower pressure has 
declined to 5 millimeters hemoglobin on an average. By 
new determinations of the capacity or if necessary by an 
X-ray ope can ascertain at any time the result 
of this treatment* 
With some patients we combined the negative pressure 
procedure with the injection ol ?v eg! - '.psin solution. 
According to the good r ecommenda g i o -. r -r: this agent 
given to several persons by PAYR, w- euocted firstly 
that it should dissolve the thick fibrin clamps as 
well-as the other residuals of the former hemorrhage, and 
secondly a modification of the thick pleural callus and 
therewith better conditions for the expansion of the 
lung. Unfortunately, we did not observe convincing 
results, as the subseouent operations revealed. 
The most promising of all conservative methods is 
without doubt the negatiye__pressure_ treatment. Until 
now it has been used with 9 wounded men with a residual 
ca'rity following a hemothorax. With 5 patients success 
was achieved by means of this treatrer ; r* n obtaining thoir 
health and fitness f#r military series. The other L of 
these patients had to undergo a cer ..psrr tperutfoa, 
With one of them the cavity had dlm.ir is tec so that the 
operation could be made less extensive while "he reduction 
with the other ones must be considered as dubious., 
With the patients, treated without success, it was a 
waste of time. On the other hand, the conservatively 
healed cases rsoul red 16 punctures on an average me a 
stay in the hospital for 5 months, The rr suit s with 
the wounded soldiers, with which the residual cavity 
following hemothorax was removed by means of a thoraco- 
plasty, are very satisfactory compared with these 
figures. If no speeial incident happened, they left 
the hospital even within 3 to U weeks. When comparing 
the results one must consider that even with a careful 
control no security is iven concerning the cavities which 11 
remain after the negative pressure treatment and which 
are associated with the danger of a later comlication, 
while by means of the thoracoplasty the ficus of dis- 
ease is radically removed. Therefore, unless showing 
improvement the negative pressure treatment should not 
be continued for to# long a period, and the cases which 
are suitable for the conservative method should be 
selected carefully. Conclusive directions cannot be 
given considering the small number of our patients. 
According to our observations the negative pressure 
treatment fails with cavities of more than 100 cubic 
centimeters capacity and above all with th#se shown 
to contain bacteria. With these latter cases it is 
more advantageous to carry out the thoracoplasty imme- 
diately and to abstain from the puncture treatment. 
It is unnecessary to describe our results in de- 
tail. With all wounded men the phenomena of dis- 
ease disappeared after the operative or conservative 
treatment. After recovering from the operation they 
were transferred into a special hospital for patients 
with gunshot wounds with the missile remainin'; in the 
lungs for the purpose of their after treatment. Heal- 
ing was obtained with all cases and there is the foun - 
iatlan far the belief that a great number remained 
their complete fitness far military service who without 
an energetic action would have fallen into a severe 
dhronic dehabilitation. In spite of this pleasant re- 
sult it is necessary to inruire if tin.ro was .10 
possibility to avoid the develc pn.cuv • " a a eside e 1 
cavity of the hem»thorax in the beg.-.nr:ny by adec aa(:e 
prophylaxis. Late criticism is always an unpleasant, 
matter. But since it shows a way how tc prevent in- 
juries, the impression which I gained when looking 
through the hospital reports, might be of some value 
for the wounded mefij The report can be summarized as 
follows. First, with the penetrating gunshot wounds 
in the chest the removal of the accumulation of blood 
in the thorax had not been done in good time and 
secondly that the punctures had not been repeated fre- 
quently enough. The cause cf this failure is tc be seen 
in the fact that the •ccurrence cf a posthemorrhagic 
pleuritis after an accumulation of blood in the pleural 
space is not sufficiently known or n,. I 0 *; all known.. 
Clear con sec nonces resulted from t a e fern- Mon r f o ..-i-dates 
connected therewith, This process ;; s cf u err re me ly 
unfavorable effect when during the removal of the hemor- 
rhage, whether by carelessness or consciously by false 
suppositions, air enters. The same is not absorbed 
by the inflamed pleura or at least is only slowly absorbed 
and can contribute to the development of cbe residual 
cavity following hemothorax in the same as H1IL1R 
and GRAF have shown for the development of t.ie empyema 
residual cavity. 
Without doubt the residual cavity following hemo- 
thorax is an aspect of disease which - part icul ‘.rly 
to war surgery and is entirely unknown. In single 
cases I had seen it, however, after puncture wounds and 
rib fractures after secondary hem»thorax. It can 12 
be assumed that some wounded men after an unsuccessful 
treatment on account of a formation of callus are re- 
leased after a penetrating gunshot wound into the chest, 
behind which such an old cavity is hidden. This 
complication could have therefore a certain importance 
for the medicine of treatment; and JAHN 
already have called attention to this after the last 
World War that also the clinically ntninfectious hemo- 
thorax may. cause pains which last for many years. 
The assumption is not to be rejected that the hemo- 
thorax residual cavity with its serious shrinkage phe- 
nomena is to be taken into consideration as the cause of 
the considerable distortions and dislocations of the 
heart and of the mediastinum as well as for the numerous 
pains after gunshot wounds in the chest. Therefore 
I hope that my statements concerning the occurrence, the 
knowledge, and the treatment of this aspect of disease 
may contribute to protect many wounded men from the 
dangers of this complication. 
SUMMARY 
With the hemothorax after penetrating injuries 
of the chest, in spite of freouent punctures there re- 
main occasionally large closed residual cavities in 
the thorax which appear in the X-ray picture only as a 
callus or are thus interpreted. By the absorption 
of the products of disintegration of protein many 
phenomena of disease arise. They disappear, however, 
after the operation of the hemothorax residual cavity. 
These cavities can be partial nr total in size. It 
depends on the posthemorrhagic pleuritis. The infection 
has a decisive influence on the development* The diagnosis 
can be ascertained by the radiographic demonstration of 
the hollow space. The aspect of disease itself is 
caused by a chronic intoxication and can easily be 
recognized with some experience. Smaller hollow 
spaces can be cured by negative pressure treatment 
while larger ones reouire a large thoracoplasty in 
order to avoid more severe injuries. The experiences 
made with 2A patients Concerning the aspect «f disease of 
the hithert# still linknwln hemothorax residual cavity 
are given* The same occurs chiefly after penetrating 
gunshot wounds in the chest and occasionally after stab 
wounds and fractured ribs* Surgical Clinic of the University of Giessen 
Director: Prof, Dr. BERNHARD 
EXPERIENCES WITH HELLER*» LATTICE PLASTIC 
IN 100 EMPYEMA RESIDUAL CAVITIES, TREATED OPERATIVELY, 
By 
Prof. Dr. Fr. BERNHARD 
with 20 Illustrations 
Translation prepared by: 
U, S# Naval Technical Unit, Europe, (Medical Section) 
Office of Naval Advisor 
Office of Military Government (U# S.) 1 
•j2S£3.tAv_e_me t ho d s_£or_c_l o 3 ing_tjhe_r e s i_dua2_£av_i.;£;£, 
In the last few decades the closure of the empyema 
residual cavity has kept surgery busy, ienerally 
acknowledged no method, which was reliable and not risky 
has as yet been found. From time to time new proposals 
word Biado to improve the usual ‘methods of treatment. 
They also prove that in this field we have to deal with 
a surgical problem not yet solved in a satisfactory way. 
On principle we have three possibilities at our dis- 
posal, The first method of treatment consists in opening 
the rigid armor surrounding the shrunken lung#in cases of 
a chronic pleural empyema. Certainly the best physiological 
method is the peeling offv of the serous coat of the lungs 
according to FOWLER and DFLERME with the aim to enable 
this organ to expand again. But this involves consider- 
able danger and has not been used by us consistently 
because of other disadvantages, 
The second possibility gives up a reexpanding of 
the lungs and makes the cavity disappear by bringing the 
mobilized thorax wall to the surface of the lungs after 
ribs,and if necessary, the hard layers of the pleura have 
been removed. As early as 1878, SCHEDE for the first time 
removed not only the ribs, but also the solid parts between 
the ribs, so that only a flap of skin or skin muscle and 
scapula remained, SCHEDE*s plastic operation allows the 
obliteration of all empyema residual cavities with the 
greatest, but not as was first believed, absolute safety. 
Failures occur with cavities which are situated mest un- 
favorably within the cupola pleurae and the costovertebral 
angle, as well as in the posterior mediastinal area, so 
that afterwards it must be filled up with a ’’living 
tampoon”, The most important thing is the experience 
that SCHEDE*s plastic operation considerably endangers 
such patients as have suffered severe injuries owing to the 
long duration of their complaint and to the chronic 
secretion of pus and that it often ends fatally, even if 
they were performed in several stages. If patients sur- 
vive this grave operation, a considerable mutilation of the 
thorax and on account of the removal of the intercostal 
nerves a paralysis of the abdominal wall remains. The 
numerous proposals for irprovement could not ouite re- 
move these and other disadvantages of the thoraco-plastics 
of the empyemal residual cavity. 
The third possibility consists in peeling off the 
serous coat of the lungs combined with plastic compression 
of the thorax. This procedure succeeds sometimes but not 
always, and therefore cannot be recommended routinely. 
In 193A, HELLER described a new procedure for the 
removal of the empyema residual cavity. This method 
doubtless belongs to the second group. It avoids the dis- 
advantages of SCHEDE*s plastics and has numerous advantages, 
I have used it in nearly 150 empyema residual cavities, and 
in each case could close the cavity, even in the cupola 
pleurae and. the posterior mediastinal space, Of my first 2 
hundred cases, I lost only 3 patients after the operation, 
but even this small number, as we shall see, was not due 
to the operation itself. The progress resulting from 
HELLER*s method compared to SCHEDE1s plastics is so 
great that I feel obliged to describe my experiences of 
the first hundred cases of empyema residual cavities that 
I personally operated a"cording to HELLER. Above all, 
every surgeon who knows this method of treatment and 
performs it with exactitude is enabled to close every 
residual cavity, how ever complicated it may be, and if 
he has only small xperience in this field he is not 
puzzled anymore by the numerous modifications of thoraco- 
plasties, as to hich method of treatment to choose accord- 
ing to the directions "iven j n the manuals of surgery. 
HELLER named his method of treatment "Lattice plastics” 
It was illustrated excellently by KLEINSCHHIDT in KIRSCH- 
NERS ‘’Science of Surgery" (ill, l). So I describe this 
method in 00 far as it is absolutely necessary in order 
to understand the follwoing explanations. 
Above the lower section of the residual cavity one 
rib is resected subperi ost rally, Then follows the splitting- 
open of the pleura callus in the middle section of the 
exposed periosteum in the line of the remov'd rib*. By 
palpating or probing, the size and extent of the cavity 
may be ascertained. Then all the other ribs above the 
residual cavity arc subperiostrally resected step by 
step. The ribs should be removed anteriorly. , 
3 centimeters beyond the edge of the cavity, while pos- 
teriorly they should be removed as far as the transverse 
processes, even if the cavity does not extend so far to the 
rear. By splitting uy the.pleura call us in the middle and in 
the line of all the removed parts of the ribs the inter- 
costal vessels and nerves are preserved, and above all li- 
gaments of the soft parts ar' created consisting of inter- 
costal muscles, pleural callus and periosteal striae. They 
can early be made mobile and with correct technioue they 
hang down so loosely that the}/ can often fill tip extremely 
deep cavities. Placing oomo tampons, drr.iha^ojtubes and 
approximation sutures complete- the operation. 
So far only SALZER and SARAFOFF have reported about the 
advantages of this modern method. But during the war, as 
I often learned, it was used far mom freruently than the 
scant reports make one suppose. As early as 1935, WANGEN- 
STEEN, too recommended the use of soft part ligaments for 
closing empyema residual cavities. In 1934, I too, made 
a thoraco-plasty on the same principle. But I did not take 
into consideration splitting open the rib periosteum in 
the m: ddle which prevents injuries to the inter- 
costal vessels and nerves and thus irregularities in the 
nutrition of the soft part ligaments as well as the form- 
ation of abdominal hernia©, I opened the callus along 
the upper border of each removed rib. 
After getting to know of HELLER1s far superior method, 
I gave up my technioue, and when the war came with its 
numerous and extensive residual cavities I used lattice 
plastics exclusively in operating them. In 1943, I re- 
ported 20 cases, all successfully provided for according 
to HELLER, The further plastics, too, yielded such fine 2a - 
Illustration 1 
Lattice plastics according to 
HELLER. 
a) The skin, the trapezius and 
rhomboideus muscles are cut and 
the ribs exposed. The sixth 
rib is removed subperiosteally 
for 6-8 centimeters length. The 
inner periosteum is split open 
by the rib probe introduced in- 
to the cavity through the ; 
fi stula, 
b) According to the extend as- 
certained, the ribs above and 
below the tne removed first are subperiosteally removed too. 
The intercostal muscles and the periosteum are held by bridle 
bandages, so that the cavity may be surveyed well. 
c) The ribs 2-7 have been 
removed subperiosteally. The cavity is laid open so that it 
is easy to survey. 3 
results that cases of r sidual cavities were sent to me 
from many quarters for operation* 
Thus my lattice plastics numb red one hundred, oven 
two years ago, I am going to give an account of the first 
hundred cases, as sufficient time has passed to allow one 
to judge about a lasting success,,At the same time I 
can compare it with my experience gathered in a great 
number of other operations, I think the communication of 
my observations is the more justified as lattice plastics 
fulfil all the reruirements for the aspect of so grave a 
disease as the empyema of tb* j*«sidual cavity; Low 
mortality and full certainty of success, not to speak of 
the other improvements on SCHEDE!s classic plastic oper- 
ation, It is of importance that I operated nearly all 
the patients myself and studied this disease thoroughly, 
I was of opinion that, as in many other methods of 
operation* very often apparently unimportant trifles are 
decisive, and I made it my business to examine and study 
all the points of view personally on which the success of 
lattice plastic might depend and my assistants supported 
me loyally in every way. 
In judging our experience with HELLER*s method wc 
think it necessary to give a short survey of our patients. 
Only isolated cases of pleural empyema were treated in our 
clinic before. As far as I know, residual cavities re- 
mained only in abofct 5%, if some care and right comprehension 
were shown. All the other cases were sent for operation 
to our clinic from outside. 
16 patients had had pneumonia before. 2 had bronchial 
pneumonia, whilst 82 had received injuries of the thorax 
by bullets, shell splinters, contusions or fractures of 
ribs. The operation findings yielded 71 partial and 29 
complete or nearly complete residual cavities. Of the 
former,13 showed an unfavorable site, 3 were situated near 
the cupola pleurae, and the rest in the posterior costo- 
vertebral or mediastinal area. Of the lO1"'* patients, 3 wore 
under 10, 5 over 4-0 years, 53 between 20 and 30, and the 
rest in the second or fourth decade of life. Finally I 
must mention that in 8 cases unsuccessful thoracoplasties 
had boon undertaken previously by other physicians. 
CAUSES OF RESIDUAL CAVITIES 
Ever since the asepct of disease of the empyema 
residual cavities has been known, one has been busy find- 
ing out the preliminary conditions contributing to its origin 
Opinions agree as to the causes, but not as to their 
freouency. Therefore, I give a short survey of the find- 
ings which according to the hospital records and the re- 
sults of operations caused the residual cavity. I wish 
to add that similar percentages are to be expected in the 
second hundred cases. 3a 
Illustration 2b 
could not be re- 
produced with the 
facilities available. 
Illustration 2a 
could not be re- 
produced with the 
facilities avail- 
able. 
a 
b 
Rib ring formed after re- 
section of the rib and 
drainage, 
Formation of a ring 
between two neighboring 
ribs after BULAU*s drainage. 
Illustration 2 
Special findings in ribs in thoracoplasty. u 
TABLE 
The Causes of an empyema, Residual Cavity in 100 Cases, 
1) 
mistakes in drainage (occasionally 
with cavity behind it) 
a) too narrow 
b) too high 
only fistul 
c) too deep (compare 111, 3) 
d) too far forward 
27 
2) 
formation of callus by puncture 
and rinsing continued too long 
25 
3) 
Closed cavities 
IB 
4 
Bronchial fistula 
16 
5) 
Osteomyelitis of ribs 
6 
6) 
Pockets 
3 
7) 
Tuberculosis 
2 
8) 
General condition of health 
2 
9) 
Foreign bodjes 
1 
This table shows that in 21% of our patients the 
empyema residual cavity was caused by errors in drain- 
age. Especially a space too narrow for drainage pre- 
vented curing of the chronic empyema. Some patients were 
sent to the cli nic for a fistula of the thorax secreting 
only little pus, bmt having existed for months. Close 
examination and X-rays showed that behind such evidence 
astonishingly large cavities may be hidden. We had the 
same experience when the elastic drainage-tube, lying 
in the area of resection, was so thin that pus could 
not sufficiently discharge itself, as urgently required, and 
so the residual cavity was formed. 
I observed that those froeuent failures in the treat- 
ment of empyema arc due to the insufficient knowledge of 
thoracic surgery of the surgeons. ABbve all, they do not 
take into consideration the normal tendency of the place 
of drainage to contract whach afterwards becomes rigid, or 
is transformed into a bony ring. (ill, 2). hen, in chang- 
ing the dressing, the thick clastic drainage-tube is 
replaced by a thin one too eirly, accumulation sets in, oven 
if small quantities of pus arc secreted and the cavity re- 
mains. 
Though I could always demonstrate in my clinics, how 
after widening the fistula or introducing a thick drain- 
age tube the general condition of the patients improves 
of normal appetite comes back, I observed again and again 
fhat my own assistants had this incomprehensible inclination, 
therefore I ordered, if conditions allowed it, the drainage 
tube only to Jae shortened, but not to be replaced by a thin 
one, when the dressing was changed. 
The after treatment of a pleural empyema needs special 
care even in apparently regular cases. Resection of ribs 
and use of an aspirator are not sufficient. At every 
inspection one should make sure that the aspirator works • l±Q. “ 
Picture from front to back seems 
t* represent a narrow cavity„ 
But the picture from the 
side shows the real extent. 
Note especially the long 
narrow fistula passing into 
the broad based, lower bounda- 
ry of the cavity. In such a 
case, a resection of the rib 
at the base of the cavity 
must precede the plastics and 
sometimes it brings recovery. 
This frenuent findin- is often 
misunderstood or not proper- 
ly recognized. 
Illu str ation 3 
Contrast illustration of an empyema residual 
cavity fr»m two sides,Residual cavity, L»ng 
drainage canal. 4b 
Illustration 3 
c 
StatJ© after the thoraco- 
plasty. First and second rfb 
preserved. 5 
well, and the negative pressure actually exists. The 
elastic drainage tube is frequently stopped up, often 
by thick clots of fibrin*. As the 1 ithotiv for "the*' 
surgical treatment of empyema I should, luce to mention 
a sentence which C, FGGERS wrote down as the result of 
his great experience: "In treating an acute empyema it 
is not only necessary to form a well fitting opening, 
but also to preserve it,” The surgeon who takes this 
advice seriously will avoid the development of residual 
cavities, 
Surely the choice of the rrsection site is of . 
importance, I prefer the deepest point of the pleura 
cavity and generally oVcr the ninth and tenth rib entering 
somewhat back of the posterior axillary line. Though 
afterwards the diaphragm will raise, I avoid placing the 
drain too high because otherwise pus is accumulated in 
the costophrenic gutter (DENK). I saw several, especially 
a l_r e si. d ua l_c ay i t i e s , no doubt caused by this mis- 
t ake , 
Another measure not too well known to avoid empyema 
residual cavities is roentgenological examination (111* 3)* 
A survey photo of the lung is not sufficient to state the 
cure of the Pi eura empyema before the drainage is finally 
removed. To serve this purpose a filling of the fistula 
should be made in every case* And, to avoid errors, I-~:RI0!s 
method is to be recommended here. By this method one often 
finds, after injection of a contrast medium, in the 
X-ray itself, oven in cases of insignigicant secretion of 
pus, contrary to expectation, an enlargement of the fistular 
canal at its end or even a small cavity in the thorax. 
In these circumstances the drainage must be continued to 
avoid great damage. In spite of removing the clastic 
tufce, the fistula often closes. Then a closed empyema 
residual cavity remains which spontaneously perforates 
after months or years or by manifestation of disease 
enforces reoperation. 
A number of patients aeon:red a chronical empyema 
by gross mistakes. Either the treatment by suction and 
the drainage wore not continued long enough or were 
stopped too early because diminishing secretion of pus and 
improving general health were considered as symptoms of 
recovery. There undoubtedly are empyema residual 
cavities where every criticism is unjustified. On the 
other hani I am convinced that by correct drainage 
combined with an appropriate after treatment numerous 
empyema residual cavities can be avoided* 
The table shows as the next most frenuent cause 
the .formation of callus with 25% caused by puncture and 
rinsing continued too long. No doubt this treatment 
occasionally succeeds in curing an acute pleural empyema. 
But if there is thick pus with large clots of fibrin, 
we risk that they form a deposit on the pleura causing 
a considerable thickening of the pleura, which seriously 
delays »r even makes impossible the complete expansion of 
the lung, oven with strong suction. In such cases a 
resection of ribs and the establishment of a continuous 
suction drainage should not bo delayed more than two 6 
weeks, For this indication one should not rely alone 
upon the decrease of temperature or i;< proved general 
health alone. 
The percentage of failures in empyema treatment 
is rather great. Probably this is due to the abnormal 
conditions in every war* Probably many a soldier's ribs 
would have been resected earlier, had the setting up 
of suction drainage not influenced his evacuation 
possibilities or had not points of view been of 
import ance* 
The third place with 18% is taken bv closed empyema 
residual cavities. This number, too, seems to bo con- 
siderably i fluenced by the war. Scv r \1 path nts had 
pleural empyema that at first had been treated opr natively, 
The fistula closed spontaneously but a res? dual cavity 
remained giving rise to symptoms of disease pasting for 
months, -very experienced thoracic surgeon knows such 
cases. Wounded patients developed a hematbthorax from 
the wound which was treated by puncture. Just in such 
a case, favored by an infection not too virulent, a 
closed residual cavity often remains, which influences 
unfavorably the general condition. Based on my ex- 
perience and thorough occupation in this field, I usually 
resected a rib over the callus, if clear symptoms of 
diseases were stated, whenever callus had been developed 
by proceeding empyema or wound, and could bo demonstrated 
in the X-ray, Every operation revealed a cavity in the 
thorax, which I a, ■ Id cure by subsoouent thoracoplasty, 
I could demonstrate, that after hemorrhage into the 
thoracic cavity, the so called hematothorax residual 
cavity occurs. 
Pleural empyema whi ch escaped notice may also 
result in residual cavities. FGGFRS described such an 
example which had been discovered 23 months after 
influenza, We also made a few observations of that 
kind, Generally such closed residual cavities are com- 
bined with bronchial fistulae through whr'ich the pus can 
be secreted. XONJETZNY saw two such cases, where the 
pleura, empyema had not been noticed for IB years on 
account of a forgotten drain tube. There are also some 
cases among our patients, wh re great empyema residual 
cavities existed for years, and where by misinterpretation 
of the callus in the X-ray, the origin of the 
purulent sputum was not props■ly explained, T'ro patients 
who were soldiers, were even reported fit for service 
(111. A). 
If one sees such patients with total residual cavities 
one scarcely believes that the human body can stand a 
strain like this for years, and that recovery can be 
possible by applying a thoracoplasty with obliteration 
of the bronchial fistula. 
In the classification of empyema residual cavities 
those cases belong in the group of bronchial fistulac 
(111. 5). According to the table, they ore the cause in 
16%. In our table they have the fourth place, accord- 
ing to thrir frequency, whereas other investigators have 4a - 
Illustration 4a could 
not be reproduced with 
the facilities available. 
Illustration 4b could 
not be reproduced with 
the facilities available 
a 
b 
Contrast filling of the 
cavity before the plastic. 
Fluid level. Some con- 
trasting medium enters the 
lung. 
Condition after total 
plastic w: th preservation 
of the first rib* 
Illustration 4 
A total pleural empyema not recognized 
through three years. Purulent sputum by 
a great bronchial fistula. Lattice 
plastic in two sessions* - 6b 
Illustration'5 
Contrast medium has sprtead into 
the lungs after a.> reontgenolo- 
gical demonstration of an empyema 
residual cavity with bronchial 
fistula, 
Illustration 6 could not 
be reproduced with the 
facilities availably 
Illustration 4 
Transformation of ribs (form- 
ation of rings and syncstoses)and 
osteomyelitis of ribs after 
multiple injuries by shell 
splinters as the cause of an 
empyema residual cavity* 6c 
Illustration 7 could not 
a b 
be reproduced with the facili- 
ties availably* 
a 
b 
Illustration 7 
Special findings of ribs in thoracoplasty, 
a) Osteomyelitis of ribs with development 
of a cavity, A small splinter is still 
sticking partly in the rib and a small 
part of it may still be seen in the cavity, 
Ti) Bony plaques arising from ribs after 
preceding plastic. 7 
described them as the greatest obstacle for curing re- 
sidual cavities* An explanation for this may be that 
small and very small fistulao were not considered in 
our tabulation if progress and findings clearly showed 
that other influences had to be made responsible for 
the development of the chronic empyema. 
It is little known, that achornic osteomyelitis 
of the ribs, too, may be the cause of an empyema re- 
sidual cavity (111* 6)* This was true with 6,1 of our 
patients. In some impressive cases with formation of 
a sequestrum the cavity secreted its pus into the thoracic 
cavity and thus gave rise to a constant recurring re- 
infection (111,7). Our first case in this regard showed a 
renewed formation of abscess- after periods of months when 
cavity and skin thrice seem to have been cured, I re- 
solved therefore te perform a subperiosteal resection 
of several ribs over the repeatedly recurring focus. 
In doing so, I discovered an osteomyelitic focus on one 
rib, by removal of which final recovery, aftfr two years of 
illness was attained. 
In a similar way the often num rous and grotesque 
pockets of the residual cavity too, support thr chronic 
empyern, By expansion of the lungs the c anal uniting 
the pockots is slightly narrowed, changed into a thin 
fistula, or even totally blocked. Such pockets like 
a diverticulum maintain the infection of the chief cavity, 
as their accumulated contents are a favorable culture 
medium for bacilli. Such conditions often cause an 
apparently unintelligible increase of temperature. 
In only 3% the existence of an accessory cavity 
was made responsible for the failure of the curative 
treatment (ill, B), This calculation as well as that 
of the bronchial fistula is based on really convincing 
observations. Probably wc have to take a greater 
number for granted here too. In many cases the develop- 
ment of pockets surely has contributed to the per- 
sistence of the empyema residual cavity. 
In the case of two patients a bad general condition 
might have to be considered, A discussion of those 
cases can be spared. 
But we have to explain the enumeration of tuberculosis 
in our index, as we excluded from the very beginning mixed 
infection pleural empyemac from the report about the 
lattice plastic. Both patients were sent to us for 
operation on the supposition of an empyema residual 
cavity after a preceding pneumonia. In the case 
of a 26 year, old woman an unsuccessful thoracoplasty 
and -n the case of a man of almost the same age a re- 
section of ribs had preceded. The cavity of the woman 
healed slowly after the secondary operation. By scraping 
out the fistula, tissue was taken for a histological 
examination which showed indisputable tuberculous changes. 
The cavity healed completely and the woman patient re- 
gained full health afterwards, while an the case of the 
man a fistula remained. During the treatment a severe 
spondylitis tuberculosa began and in addition to that a 
fatal miliary tuberculosis. 7a 
Illustration 8 
Empyema residual cavity with 
bronchial fistula and 
accessory cavity. 8 
The impression in both observations was, that one 
!ad to deal with postpncumonia partial residual cavities. 
It is justified to suspect that this was based on a 
specific infection. It is possible, that errors in 
this regard occur often. Nevertheless I enoted both 
cases in the index of the causes of the empyema residual 
cavities because the discussion of these pathological 
symptoms is very instructive. There arc reports of 
chronic suppurations of the pleura, which at first 
seem to be trivial, but later on prove to be tuberculous, 
J, ALFXANDFR alone described 8 observations which, 
although operated already, came with a fistula to him 
for treatment. Exploratory excision showed in all cases 
only ordinary sjwnptofns of inflammation at first. At 
a repetition aft eh several months, however, there were 
to our groat Surprise little tuberculous knots. 
In case of our two patients it is not possible to 
prove convincingly if, in spite of apparently incon- 
testable precedence and progress up to the plastic, 
there existed a postpneumonical or a mix-infcction 
empyema from the beginning. In both cas; s it stems 
rccommcndable to use exploratory excisions of the plcur al 
callus at the t horac opl as ty itself, in gw- of bad 'wal- 
ing and first of all always before each subsequent oper- 
ation. 
After this digression, wh? ch w:.s necessary to 
avoid repetitions in a later chapter, we still avo to 
discuss the last cause of the empyema rr si dual cavity. 
Contrary to other statistics, in only the ease of one 
patient a chronic empyema residual cavity did not heal due 
to a foreign body. In this case it was a rubber tu.be 
of 8 centimeter length (111, 9), that had slipped un- 
noticed into the pleura cavity and thus maintained for 
one year a totally closed empyema residual cavity with- 
out any connection with the bronchial tree. In some 
plastics, parts of projectiles, especially shell-splint ors 
were found, which had not been taken into consideration 
as they were not the decisive cause for the existence 
of large cavities. 
With this summary the most important causes are 
discussed. This table surely has the disadvantages 
of every scheme. Without doubt, in the case of some 
patients several factors had to be regarded, but it was 
difficult to determine the most important one, 
A further disadvantage is that the pleural empyema©were 
n«t treated by us according to homogenous rules after 
resection of the ribs, but nearly all came to our clinic 
with an existing residual cavity. Clinical records used 
for research of the origin of an aspect of state may 
result in mistakes. Surely grave omissions in after-treat- 
ment, especially insufficient breathin’ gymnastics, ,rc 
not aporopriately mentioned. On the other hand the sur- 
vey of so groat a number of patients s' ows in a general 
way what has to bo done to avoid the origin of the dreaded 
empyema residual cavity. 8a 
Rubber tube in the survey- 
picture , 
Condition after lattice 
plastic which shows the 
extent of the surgical obi. 
liberated residual cavity. 
Illustration 9 
Rubber tube in the thorax as the cause 
of a closed empyema residual cavity, is 
easily overlooked, if tho film contrast 
is too faint , 9 
THE_INDICATIONS 
There is no generally authentic indication as 
to the moment of the operation. Some manuals suggest 
not to wait more thin 2 months, Fvon in case of a 
bronchial fistula this period is too short. Generally 
the cure of large cavities of adults with chronic 
suppuration from the thorax cannot bo expected anymore 
after a lapse of 6 months, on the other hand PERTHES, 
HARTERT, NEVILLE, GOETZE, WP'STHUFS, etc., furnished 
proof that they can be cured permanently by a suit- 
able suction treatment, oven aft-r a longer period. 
One therefore, must have the guarantee that this treat- 
ment is or has boon conscientiously performed before 
the operation. Though old cavities c innot be closed, 
they are often reduced so that a smaller plastic 'will 
be sufficient. We therefore treated every chronic empyema, 
that has been treated before by oth rs, again with a 
suction treatment and used a very strong suction. Even 
in apparently hopeless cases wo gained progress by 
using the water-jet suction apparatus. Opinions differ 
as to the employment of negative pressure in case of a 
bronchial fistula. Surely, chances are more unfavorable 
in this case, but on the other hand cures of empyema 
residucal cavities arc possible this way. It is re- 
commendable to interrupt the suction fr in or-mr 
to enable the bronchial fistula to heel. 
Because of those different treat rnts we succeeded 
in closing every fourth or fifth empyema rrsi dual cavity 
that was sent to us for plastic, without any operation. 
It is to be understood, that no precious time may bo 
lost by conservative treatment. Complications rising 
in the brain arc especially dangerous here. Although 
they arc rare, I ordered the collection of all cases of 
cerebral abscesses and meningitis, which occurred 
during the last decades with acute and chronic empyema 
residual cavities in the clinic of Giessen. They uni- 
formly cover such large periods of time that there is no 
special hazard during the first or second 6 months period. 
The possibility to close or reduce the cavity is so 
groat, that there is nearly no objection to chance either 
cerebral complications if conservative treatment is con- 
tinued, or the danger of the well known toxic damages 
(amyloidosis etc,) Nevertheless the moment of th« oper- 
ation must not be postponed unnecessarily. An exact 
fixation of the moment is therefore necessary. It 
certainly has come, when a further diminishing of the 
cavity cannot be expected. Today this moment can be 
fixed by X-ray pictures of the residual empyema taken 
at various periods of time (111, 10), We therefore 
make X-ray controls every X weeks. According to our 
experiences a further diminishing is not to be expected 
if, in spite of intensive sucking treatment in connection 
with breathing gymnastics, no reduction in the. extent of 
the contrast-shadow is recognizable in the X-ray picture 
after 4-8 weeks. 9a 
View from front t* back. 
View from tho side shows the 
extent of the cavity and 
especially the pockets and 
sack formation* The long 
fistula canal is striking as to 
be sen also in Illustration 3. 
Here too, a resection of ribs 
at the base of the c wity has 
to precede the plastic. 
Illustration 10 
X-ray picture of an empyema residual cavity 
from two sides. 10 
Greatest caution, howcv r, should be used in the 
evaluation of the X-ray clotures,' To determine the real 
extent of the residual cavities, X-rays from two sides 
always hav to be made. The differences arc considorable, 
We learn, by comparing with operation findings, th t the 
cavities arc always larger and more ext-a si ve than appears 
in the X-ray pictures. Larac accessory eviti-s, 
connected with the chronic empyema only by snail openina, 
and the often numerous small pockets reyularily escape 
roentgenological detection. If thick fibirin-clots arc- 
in the residual cavity, a less extensive cavity may bo 
suspected. The filling of th fistula may be negative 
and yet a cavity exists all the same. I point towards 
the value of MERIO’s method to ovoid deceptions. 
Every precaution Is to be used in case of a 
bronchial fistula. In one case we saw thorotrast enter 
the sound lung by reflex action. Such events must ab- 
solutely be avoided (ill, 11). In case of a bronchial 
fistula wo have to abandon X-rays as the danger of 
chronic and acute damages is too great. 
PREPARATION 
One of the most important conditions for success 
is a careful preparation* In this case several points 
of view have to be regarded which do not have the same 
significance in an ordinary operation. First of all 
we place the care for detoxication, next comes the 
removal of damages caused by chronic suppuration and 
finally the increase of protective power of the patients, 
who are tiofct often extremely weakened* 
Though the influence cf detoxication on the success 
of surgical operations in case of fecal stagnation uith 
carcinoma of the large intestine is well Vnown, one is 
always surprised to see how seldom this knowledge has 
been used in the treatment of the residual 
cavity. We never operated uoon any patient, if before 
the operation the outflow of the pus from the pleura 
cavity might be influenced in the least. Any narrow 
fistulao arc always dilated. If this was not possible 
on accout of the formation of narrow-bone rings at the 
place of drainag , the resection of ribs was repeated. 
After this simple method of treatment the general 
condition improves as a rule. Thereby above all th; ngs 
the cavity and the operation can be made the smallest 
possible. In several extremely grave cases one or two 
ribs at the lower end of the cavity were removed to 
begin detoxication as quick as possible and to make it 
effective. It cannot bo emphasized enough, that 
SCHEDE?s classical method of treatment requires in the 
first act a subperiosteal resection of the lowest rib 
and thereby a broad opening at the base of the empyema 
residual cavity, and by this to provide the Kest con- 
ditions for the drainage of pus. 10a 
Illustration 11 
Condition after thoracoplasty because of left- 
sided empyema residual cavity with bronchial 
fistula* During the roentgenological presentation 
before the operation, Thorotrast was aspired into 
the right lung after a cough irritation, and is 
to be recognized months afterwards by the numerous 
coarse spots. 11 
Irrigation treatment assists detoxication effect- 
ively, Numerous exp rimonts revealed that disinfection 
of a residual cavity cannot be expected. Its effect 
seems to be only mechanical. It has to wash out the 
albumin products of disintegration to prevent a toxic 
damage of the organism. The kind of rinsing fluid used, 
is immaterial; we use solutions of Rivaaol. io did 
not observe any special advantage in introducing 
sulfonamides into the empyema residual cavity. 
Irrigations must bo used first of all in cases of 
residual cavities, which secrete putrid, foul pus because 
these patients are extremely damaged and more liable to 
relapse, even if the plastic is of small extent. There 
is a statement of a research from E, SCHNEIDER about 
the toxic . off ct of foul pus in case of pleural empyema. 
He traces it back to the decay of albumin substances of 
the kind of methylonacrolin and allylamin, I urgently . 
discourage a plastic as long as the pus smells fetid. 
Quite as important as the care for radical detoxi- 
cation is the elimination of the. damages caused by the 
chronic pleura empyema. Here the blood transfusion 
is the decisive matter. Only today can we fully 
estimate its importance. Even during the first World 
War FAIR referred to the dimunition of the hemoglobin 
values in cases of pleural empyema and demanded a more 
frequent check to evaluate the aspects of disease. 
This was not done until during the last war (1939-194-5) 
when WACHSKUTH, DUESBFRG and SCHROEDER of the special 
hospital of th General Headouartors of the Army care- 
fully explored the changes caused in the blood, by chronic 
suppurations in systematic, most careful examinations. 
The results are of great importance to understand prepa- 
ration and after treatment4 To avoid repetitions they 
will bo described fully here as far as they are of 
surgical interest. 
In case of chronic pleural ' a the damage 
by long lasting secretions of pus and the loss of protein 
connected with it, is especially pronounced. The loss 
of protein is easily to determine numerically as to its 
extent with this aspect of disease. In serious cases 
cachexia is developed by a deficiency of protein, A ' 
healthy individual disposes of areat depots of protein. 
From thorn he can deliver within 2U hours protein enough 
into the blood channel to form 1500 cubic centimeters of 
plasma. But with chronic suppurations because of the 
elevated temperature with toxic and bacterial decay of 
protein, th re developes a decrease of these depots by 
insufficient assimilation of protein and the suppuration 
itself. Combined with these processes is a deficiency of 
valuable protein building materials for the vitally 
important hemoglobin. It is followed by a considerable 
change in the picture of the rd blood corpuscles which 
finally gives the impression of a sideropic anemia. If 
ascorbic acid iron is ?ivcn there is no increase of 
reticulocytes and no amelioration of the hemoglobin de- 
ficiency, On the contrary, the erythroblastic apparatus 
is prevented from developing completely and remains in 
a macroblastlc state until th-re are sufficient quantities 12 
of protein to furnish the building material for the 
normal amount of hemoglobin. If there is an extreme 
deficiency of protein, hemoglobin will be used to 
cover the protoin deficit. In this stage in case of 
empyema residual cavities the erythrocytes decrease 
numerically and the amount of hemoglobin lessens. It 
is therefore not astonishing that wo saw the most serious 
anemics with soldiers whose protein depots had been 
much exhausted oven before the development of the chronic 
pleural empyema by the hardships of war in the east and 
by considerable loss of blood upon being wounded. 
The valuable results of the research of DUlbhBBRG 
and has collaborators, which have greatest importance 
for other branches of surgery too, explain convincing- 
ly why the transfusion of blood, already freruently 
used on the basis of practical experience with the 
empyema residual cavity, is very iraoortant for the 
preparation for the operation. The alternative - 
restitution of protein by the enteral way is- .not 
sufficient or cannot be tolerated. Only by way of blood 
transfusion is it possible to remove the deficiency of 
protein and to replace? the plasna* In c .c of consider- 
able deficiency protein even the tr sfused v.d blood 
corpuscles ill b. censured for protein to ; greeter or 
lesser degree• Thus they render nor. v .luable s.rvlc. than 
they i ight itregard to tin r cpir .tory function. Undir'- 
t:icse circu.. stances the effect of ■. blood transfusion 1 o.sts 
for . short tine only. Its effects apoo \t visibly only 
after the protein depots start to fill up again* be have 
to c a siacr tha.t possess the richest supply of protoin 
and calorics in the erythrocytes which v/o can" supply to a 
patleiat pall enter ally in liquid forn and that the highly '*■ 
valuable plaona - and henoglobin protein as a character- 
istic protein can be absorbed by the body in: ediatoly with- 
out any loss. The transfer of sorur is less ..ffectivo, ‘ 
as its protein content is only a third of that of thy cells. 
Those examinations make us understand the value of 
blood transfusions in case of empyema residual cavities. 
They enable us to alleviate protein cachexia. If this 
is done, the patient is able to endure the thoracoplasty 
and first of all the mest important post-operative com- 
plications, the operation shock and the danger of 
secondary hemorrhage, which may olace heavy demands 
on the protein depots of the patient. Blood tr ',ns- 
fusion has therefore to be repeated before every surgical 
operation until the body possesses a sufficient stock 
of protein again. We arc able to fix th:i s date to some 
extent by frecuent checks of the blood picture. Con- 
tinual controls therefore are essential to judge the 
aspect of disease and set the appointed day of operation. 
Protein cachexia diminishes as soon as transfused protein 
will be taken to form hemoglobin-protein and the ery- 
thropoesis increases, which sometimes is explained mis- 
takenly as an irritant effect. The increase of the 
erythrocytes is usually limited and seldom reaches a 
fully normal level before the most important cause for the 
decrease of protein, the chronic pleura empyema, is 
eliminated, 13 
The objections to the employment of blooi-transfusion 
are unjustified. Fvcn with diseases of the pulmonary 
circulation there is no danger of overstrain. The 
increased circulating Quantity of blood is removed by 
storage in depots. This is a false doctrine, which has 
done the greatest damage especially in thorax surgery. 
After operations in the thorax blood - transfusions-* aa?c nearly 
always necessary to obtain good success and to avoid post- 
operative shock. 
The improvement of the general condition t i.kes the 
third place in the preparations for operation. It 
is common sense that weakened patients should be strengthen- 
ed as much as possible by food rich in calorics and 
vitamins* In many cases we injected a good euantity of 
vitamin C intravenously before the operation, but this 
showed no convincing advantage. In case of toxic damage 
of the heart and with older patients wo used a strophantin 
treatment. The psychic treatment of patients, ’ • 
who sometimes have passed a long period of suffering and 
have a serious operation ahead and the calming of the 
visceral nervous system by doses of Bellorg.il or Luminal- 
ets favors recovery, and facilitates the performance of 
the operation under local anaesthesia* 
THE. TECHNIQUE .0F..0PERATI0N 
The success of the operation is influenced very much 
by the method chosen for analgesia, It is the general 
opinion that empyema residual cavities can be removed 
only under general anaesthetics because of the h~avy 
growth of callus. This is not trtle* In case of nearly 
99% of our patients, coming from different marts of 
Germany and for a smaller part from foreign countries 
a local anaesthesia, prepared carefully and given some 
time before the operation will be sufficient, A groat 
deal depends upon the teohnioue of the injection. We 
were able to perform an extensive second thoracoplasty 
without any manifestation of main on the part of the 
patient whach was not possible at his first thoraco- 
plasty made in another hospital, where a complete ether 
anaesthesia had to be given. In case of strong formation 
of cil1us regional anaesthesia Is therefore 
the field of operation itself must be infiltrated. 
Others too emphasize the advantages of local ana- 
esthesia to remove ’ empyema residual cavities, VObSC'IULT*' 
reported from FREYtfee clinic, that postoperative mortality 
was reduced from 26,7% to 17,4% after replacing general 
anaesthesia by local anaesthesia, I have successfully 
performed without difficulties several extirpations of 
lobes of the lung ( once, two lobes in one session) 
transpleural oesophagogastrostomies and other large 
operations in the thoracic cavity which require much more 
of a patient than the thoracoplasty in case of empyema 
residual cavities local anaesthesia. f* 14 
According to our experiences it is justified to try to 
succeed with local anaesthesia in case of every lattice 
plastic and even secondary operations. If necessary, 
"S.E.E, simple solution" may be given (that is; 
Scopolamin hydrochloricum 0,0005, Eucodal 0,01, Ephetonin 
0,025). I do not advise intravenous injections of Evipan 
and Funarcon in intrathoracic The least strain 
in an additional light ether anaesthesia from which the 
patient can awake any time. With this one is able to 
judge best the degree of damage done to the general con- 
dition and avo d that the patient will bo seized with 
the always threatening danger of a shock, DEfEL too, 
praises the advantages of a slight ether anaesthesia, 
which turned out well in his use of SCHEDE's plastic. 
The technique of the operation itself is simple 
and has already been discussed in its characteristic feat- 
ures; but I lay stress upon some points of view and ex- 
periences, SALZER’s opinion is, that HELLERS method 
of treatment is of no use and can be replaced by the 
method of SCHEDE, if the pleural callus is thicker 
than 2 centimeters, HELLER we cannot agree with 
this opinion and consider the c&llus to be a valuable 
material to fill out the cavity. Even after thoraco- 
plasty with callus up to 5 centimeters thick, we did 
not observe any necrosis with marked or long lasting 
suppurations. The combination of HELLER's and SCHEDEls 
plastic turned out well. Especially in case of secondary 
and two stage operations this is the only possible way 
to remove the residual cavity, whereby the parietal pleural 
callus has to be removed in the lower sections. 
A simple additional method of treatment is recommended 
in all cases with thick callus. Here sometimes a certain 
stiffness of the ligaments is to bo observed. They 
do not lean against the lungs without a certain tension, 
thus favoring the danger of a renewed development of 
cavities. Under these circumstances I resected from the 
pleura, thickened by callus a broad based wedge at the 
posterior insertion of the ligaments at their inner side, 
carefully preserving nerves and vessels. This results in 
a total relaxing of the striae which afterwards fit easily 
into the deepest cavities. The same method can be 
employed at the front end of the striae. In employing 
this method one avoids to a great extent the occasional 
resection of ribs far beyond the anterior border of the 
cavity necessary for relaxation. 
In some cases we formed ligaments of twice the usual 
breadth. After resection of the ribs onl}?- the inner 
periosteum of every second rib was split longitudinally. 
This is supposed to assure the nourishment of the stria and 
to make the incision as small as possible. These broad 
ligaments are too rigid and it is more difficult to place 
them into the cavity. Moreover we observed that after 
this method the infections lasted longer than usual 
and therefore we declined to alter the technioue in this 
regard, 15 
Most methods for operative removal of empyema 
residual cavities reeuirc special consideration of the 
Question of how to deal with the scapula. In most cases 
VOSSCHULTE resected the lower part of the scapula to give 
soaco for relaxation to the lateral wall of the chest, 
SAUERBRUCH even removes the medial rim of the scapula, if 
by pressure against the vertebral column it hinders the 
lateral sinking in of the wall of the chest. These 
methods of treatment leave a restriction of the mobil- 
ity of the arm above the horizontal lino. All these 
functional and cosmctical disadvantages arc not to be 
found in the method of HELLER, In the first hundred 
operations I was forced only once to remove the lower 
half of the scapula as in this r ggion it was bonily 
adherent with the ribs underneath. Since then I have 
had to resect parts of the scapula in only two cases. 
They were extremely difficult secondary plastics, where 
after the proposal of SUDECK I used subscapula muscles 
to fill out a cavity situated posteriorly high and 
paravert ebrally, 
The cure of bronchial fistulas at the same time 
with lattice plastic is not difficult. Scraping out of 
the mucous membrane and ligating round the end of the 
fistula arc sufficient. Formation of striae is suffi- 
cient for cover and they close the bronchial fistula by 
means of a well nourished pedunculated flap of muscles, as 
proposed by NIESiFN in 1932, a matter which is super- 
fluous in case of ordinary residual cavities. This does 
not nr an that occasionally specially situated bronchial 
fistulac or even lattice lungs may occur, in which cases 
only NIESSEN1s proposal gives the moot certain and best 
guarantee for a cure. I too, used it successfully a, 
short time back in a ouite abnormal case, that had been 
operated four times previously in vain by experienced 
surgeons, 
With this case I used the principle of relaxation 
which was pointed out by LEZIUS in 1938, and which is 
quite sufficient to obliterate ordinary indirect bronchial 
fistulae, LEZIUS recommends the removal of the ribs 
or their regenerates surrounding the fistula within 
7-10 centimeters, to cause the recovery by the flexibility 
of the lung-tissue thus created and its shrinking after- 
wards, situation is nearly always created, if 
lattice plastic is used. Only in exceptional is 
a more extended resection of ribs than would be necessary 
for the closing of the cavity necessary to got a sufficient 
relaxation. According to HELLER the possibility of 
shrinking is great, as proved by the following obser- 
vations. In the case of a closed, total empyema residual 
cavity, that had been unobserved for throe years, we 
decided on a two stage operation on account of the bad 
general condition of the patient. The ribs 6-10 were re- 
sected subperiostrally in the first session and the thoracic 
wall was treated according to HELLER’s method. In the area 
of the hilus there was a bronchial fistula with a lumen 
larger than I have ever seen before. The fistula was not 
touched. Its closure, which caused us some Yrorry, was 
supposed to be performed in the second session. Three 
months later, to our surprise, the bronchial fistula 
had disappeared. 16 
No doubt there arc aspects of disease whore one is 
obliged to apply a muscle plastic in connection with 
a relaxation at the same time. In case of a residual 
cavity, however, HFLLERis plastic assures sufficient 
flexibility of th surrounding tissue of the lungs, and 
thereby cures th~ bronchial fi'tulae. Up to now we 
wnre able to close them all this way. In c a scs of 
secondary operations too, which were necessary with 
some of our patients the continuation of a bronchial 
fistula never was the cause of a second operation. 
In completion of this, the finding at one operation 
may be mentioned of a condition which is rarely discussed, 
but on the other hand reouires a great deal of the 
surgeon in every operation. It is gen rally known that, 
if the thorax shrinks, the distances of the ribs will 
grow more narrow and it is possible that the ribs may 
telescope like tiles. But the changes in th' ribs 
themselves arc seldom mentioned, BIBGARD made thorough 
examinations here. The roundish ribs loos' thrir shape 
above the residual cavity. They become more triangular 
or rectangular by aggregations at the lower ram and at 
the inner side. The change is especially marked in the 
area of the angle of the rib, Occasionally even synos- 
toses of neighboring ribs arise. 
According to the experimental findings of BISGARD 
the changes originate in an aseptic inflammation and an 
abnormal pulling effect on the periosteum. The first 
one seems to be more important. Generally there is 
considerable similarity to the reaction of the bone in 
the neighborhood of osteomyelitic foci. The periosteum 
is stimulated to an increased formation of bones and 
grows thicker. Above all, the bone itself thickens. 
Both developments render subperiosteal resection of ribs 
difficult in cases of empyema residual cavities, where- 
as they are easy to p-rform with thoracoplasty in cases 
of pulmonary tuberculosis. The inflammation can 
spread along the periosteum up to the joints where the 
ribs are connected with the vertebral column, and caus# 
purulent inflammations there, close examination 
the often marked changes can bo obs rved o11ite frequent- 
ly, but they ere seldom taken into consideration. But 
they must bo considered as a cause of the occasional 
appearance of the otherwise inexplicable meningitis with 
the empyema residual cavity, as we shall sec later. 
It Is a cuestion of utmost importance to decide if the 
thoracoplasty should be performed in one or several sessions. 
According to general opinion, the operation of residual 
cavities is never a trivial operation and on account of 
the preceding suppuration is always a rcat strain on th: 
v/oak patient. Therefore SCHFCF's surgical removal of all 
the ribs in one session associated with the removal of 
the pleura thickened by callus is discarded. It is 
generally believed, that several seesions are necessary 
(ill, 12). If lattice plastic is employed, the residual 
cavity can nearly always be closed in a single operation. 
With tho first 100 patients I made the plastic in two 
sessions only'in two cases. Both were in a bad condition. 
In the first operation I therefore removed only the lower 16a 
a 
Before the first plastic. 
b 
Before the second plastic. 
Illustration 12 
Presentation of a total, two stage, oper- 
ated residual cavity. 17 
4 respective 5 ribs, and closed the total cavity by a 
later second operation. In my later plastics I 
choose the two stage procedure more fremuontly, but then 
the patients were extremely grave cases, HELLER ro- 
com ends the use of more than one stage more, often. 
Today I do not consider this necessary, if preparation 
and aftertreatment arc made carefully. As secondary 
operations after lattice plastics arc especially diffi- 
cult on account of the numerous regen rates of ribs and the 
solid callus, a preceding subperiosteal resection of ribs 
above the residual cavity helps to reduce the operation 
in size. But this is only a makeshift. 
According to my experiences nearly ?.ll partial*, empy- 
ema residual cavities can be closed in a single session by 
means of lattice plastic. Patients usually endure the 
removal of 3-A ribs well and of 5-6 without considerable 
damage. Every precaution is to be used in case of total 
and subtotal cavities. As to the extension of the elastic 
I depend on my own ,1 udgement of the a a nt dur i ng t h:■ 
time of preparation, hir- general cond: tjon and his 
reaction during the operation, A careful and extremely 
conscientious control is necessary if sir ben serious 
surprises are to be avoided. If a serious shock arises, 
everything has to be stopped. In the case of several 
patients I first intended to operate in two stages, but 
after due consideration during the opor ation I resolved 
on a one-session plastic. Here the patient’s reaction 
to the operation influenced considerably the change of 
ray decision. To judge approximately the seriousness of 
the operation and to keep constantly informed about the 
extension of the removal of bones from the thoracic; wall, 
the length of the resected parts of the ribs may be 
measured continuously. Generally the removal of 60-50 
centimeters can be endured without danger. Greatest 
caution should be used, if it goes beyond 120 centimeters. 
In case of two stage operations, lattice plastic should 
preferably be started from below. If possible, some- 
how, I recommend to extent the first session ui to the 
removal of the fourth rib. On account of this I ob- 
served later on in case of several patients, who 
were to have a second session afterwards a surprising 
recovery of the upper section of the cavity. 
The length of the intervals between the sessions 
depends on the patients general condition, A period of 
at least 3 weeks is essential. Gen -r ally second operations 
are tolerated better after a long r int rval. With one 
patient I performed a small lattice plastic for detoxi- 
cation by resection of three ribs. In case of this 
severely damaged 21 year old patient who only weighed 
36 kilograms for a height of 182 centimeters at his 
hospitalization, the second session could be performed 
only after a lapse of 9 months *when his weight was stabil- 
ized between 49,5 and 50 kilograms. 
According to the development, w h i c h SCHEDF’s plastic 
has undergone during the last decades concerning the sub- 
division of the operation, one will bo critical of my 
recore ending to perform nearly all the operations in one 
session with HELLER’s method. This proposal seems to be IB 
contrary to every assured experience, 'ithout doubt 
it is possible to increase the power of resistance 
against the operation by a careful preparation and a 
conscientious after-treatment and on account of this 
the patient is able to endure more strain* Our method of 
treatment for the first and second rib surely has 
special importance in case of lattice plastic. 
In the first period of us© of thoracoplasty one 
could observe the so called vibration of the wall of the 
chest which occurred aft r total removal of the ribs. 
Today this severe complication is seldom observed after 
the operation of an empyema residual cavity. On the 
other hand, the removal of the first and second, rib is 
an additional great strain on the circulation. In the 
methods of treatment used for the removal of empyema re* 
sidual cavities up to now, the closing of the rccessus 
epitympanicus meets difficulties, even if the method of 
treatment is used, wh~ ch was first recommended by SAUER- 
BRUCH for the operation of mixed infection empyema, VOS - 
SCHULTE impressively: Even by total removal of 
the upper ribs a depression of the mobilized thoracic wall 
against the- visceral pleura of the collapsed lung cannot 
be enforced, as the shoulder girdle s t i 11 acts as a 
support, keeping the rcccssus epitympanicus extended. 
While in thoracoplasty In case of pulmonary''tuberculosis 
the first rib takes some kind of a key position and in the 
usual method of treatment for removal of an empyema re- 
sidual cavity is judged similarity, it car. be disregarded 
with total cavities, if lattice elastic is applied. Using 
this method of tr atment, I n ver removed the first rib, 
and later on almost regularity left the second rib in 
its place too, (ill, 13 and 14), The rocossus epitym- 
panicus, the closure of winch is so difficult by other 
met' ods, may be filled up easily by a careful formation 
of freely movable striae with thick callus. 
To meet the possible ob’oetion, that only light 
cases wore treated, I give a short survey of the number 
of ribs removed. In about one ouarter of the cases 
4., 5 - 6 ribs w re resected in 16 cases, 7 ribs, in' 9 
cases 8 and in 2 cases 9 ribs. To evaluate the extent 
of the operation I think it is essential to state the 
length of the pieces of ribs removed. In our last 
plastics, an average of ribs with a length of 105 
centimeters wore removed. In the case of one patient 
the total length of ribs removed in one session amounted 
to 180 centimeters. His postoperative recovery met no 
di f ficult ie s, 
The removal of ribs ma5r not bo Torformed too thrifti- 
ly or inaporopriatcly otherwise recovery even after 
lattice plastic fails and a no-* piastre w: 11 become 
necesrary, On the other 'hand not too many 'wnes should 
be removed from the thoracic wall. As I der.onst* -ted in 
a previous publication, the lung ti sue recovers perfectly 
after a lattice plastic, especially in case of young 
patients. This is explained by the important observation 
of SAUTRBRUCH that the collapsed luna is able to extend 
again, if it is still under the effect of a re- 
maining part of the thoracic wall, and that by the in- 
fluence of its function it may even recover, SAUBRBRUCH 
therefore, thaugh he urges to remov,. the bones radically. 18a 
Illustration #13a could not 
be reproduced with the 
facilities available. 
Illustration 13 
Total right sideded empyema residual 
cavity (a) before and (b) after the 
lattice plastic, with first and second 
rib preserved. 18b 
Illustratien 14a b 
could not be reproduced with 
the facilities available. 
a 
b 
Illustration 14 
Total empyema residual cavity before and after the 
plastic, 
a) Contrast filling of the cavitxr before the open tnon, 
b) State after the plastic. Preservation of the first 
and second rib. 19 
demands to preserve as much as possible of the thoracic 
wall. This apparently impossible demand may be ful- 
filled in an ideal way with the lattice plastic, be- 
cause one exposes the cavity by sacrificing no more 
ribs than absolutely necessary and moreover new ribs can 
be formed from the preserved periosteum of the ribs. 
To allow the lunas to expand, one can make some 
incisions crossing one another vertically in the callus 
on the surface of the lung. Even more effective is an 
early start of breathing gymnastics after the operation; 
special stress is laid upon thus in the after treatment. 
As to the technique of the operation we still have 
to mention, that before finishing the plastic and after 
a careful control of hemorrhage and cleaning of the 
field of operation wr. dust in an abundance of sulfon- 
amides in powderform. Usually we introduce only one 
drain occasionally two, with some gauze strips at the 
lowest point. 
A tor the operation we regularly use the rubber 
tension bandage, which has to be applied very carefully. 
By si: ght pressure it has to keep the strips in their 
position,avoid the new development of a cavity and also 
a sec olid ary hemorrhage. Because of the bacteriostatic 
power of the sulfonamides it is usually oossible to leave 
the bandage dn foi4 a week. pven in case of big cavities 
we use a slight pressure bandage in the aftortraatment, 
POSTOPERATIVE COMPLICATIONS 
To perform a conscientious after treatment, one 
must have exact knowledge of the most important com- 
plications, wh'ch in case of empyema residual cavities, 
threaten to arise after every thoracoplasty. They ought 
to be especially discussed, because only by avoiding 
the dangers arising from them is it pos iblo, to reduce 
the formerly high postoperative mortality rate to an 
astonishing low percentage. 
First of all we have to mention the shock, which 
can occur in case of lattice plastic as well as any 
other intrathoracic operation during the operation, 
and than demands an immediate blood transfusion. There- 
fore, in every case of thoracoplasty a suitable blood donor 
has to be at hand. As mentioned before, the false doctrine 
representing the greatest obstruction to thoracic surgery 
which stated that blood transfusions are bad mistakes in 
case of disease in the region of the oulmonary circulation 
has be. n abolished now. Even after an ap parently well 
tolerated plastic, patients, are freruently and sometimes 
surprisingly liable to shock. For 3 ~:rc .rs wo proceeded 
after careful observations and in spii- of all scruples to 
ake a blood transfusion i.m ediatcly after every lattice 
plastic which is the best means to avoid shocks. 20 
A transfusion of at least 4-500 cubic ccntimot rs 
is advisable after large operations, S all transfusions 
include the possibility that shock repeats in the course 
of the da.y of operation. In this case the blood trans- 
fusion has to bo repeated imrediatoly. There is no' 
rule as to which patients will bo liable to renewed shock 
symptoms after the lattice plastic is made. The danger 
docs not depend solely on the extension of the oper tion 
and the general condition. Deceptions in a good or bad 
sense occur cuite freruently. As long as we do not 
know, the cause of the shook and a reliable prophylactic 
is impossible, greatest caution in supervision is re- 
commended, In case of several patients a renewed menacing 
deterioration of the general condition could only be 
eliminated by a twice repeated blood transfusion on the 
same day as the operation. In some cases, if necessary, 
we did not hesitate to use this sovereign means of 
avoiding shock and collapse not only during the operation 
but even the first and second days postoperatively, 
Based on impressive observations and convincing 
experiences j indications, v/hr'ch r re always examined 
exactly were first Mvon cautiously and then regularly. 
Unfortunately there is no substitu- of anywhere near 
the same value. Infusions of serum are definitely not so 
effective. Periston too, should be used only, in an 
emergency. Since we make blood transfusions systematically 
right after the operation and besides that as a rule in 
case of a deterioration of the general con.d.ition we 
could desist more and more from using continuous intravenous 
clipis of physio logic a.■ saline solution mb. th additional 
circulation stimulants. In a few cases it rendered 
valuable services. 
• A'tcr the operation it must be prevented by all means 
that the chock with its grave conseouences may take 
full effect. In many regards it is justified and in- 
st uctive to compare it to the reaction of the blood 
pressure in spinal anesthesia. But if bio os pressure has 
sunk below 80 or even 60 millimeters h moglobin it is 
difficult to bring it into balance again. Just as it is 
doss:blc to avoid the threatening danger by giving 
blood pressure increasing remedies in time, a prophylac- 
tic blood transfusion succeeds in preserving patients, 
who after a thoracopl .sty arc liable to shock and 
collapse, from damage which sometimes can never be eli- 
minatad, 
The second important as well as dangerous com- 
lication is secondary hemorrhage. The clinical conse- 
oucuces are manifested in collapse* Ad the shock too 
results into collapse, the effects of the shock as well 
as secondary hv>i orrhage are the sar.o. This is the gr«at 
danger after . thoracoplasty, If a patient is not suffi- 
ciently protected against postoperative shock, secondary 
herorrhage any bv fatal* Shock causes a change in the 
composition of blood, which is narked chiefly, without 
mentioning the displacement of ions, by the oxtrav .s.ati mi 
of plasma from the vascular system. An additional loss of 
plasma, caused by secondary hemorrhage, . ay have unf vor- 
able or even, life endangering; effects, Both v.ve::to are 
cs- ocially d .nger us for atiento with pyei .a residual 
cavities, as there preceded or still exists da age due to 
the protein deficiency caused by a chronic 21 
suppuration* The depots of protein from which a healthy 
organism is able to replace its plasma in case of loss of 
blood, arc very small and soon exhausted, even after a 
good preparation. So after a collapse, caus'd by sreo:.ad- 
ary hemorrhage, cuick and effective aid as only to be 
expected from a blood transfusion. 
The origin of secondary hemorrhage, connected with 
tho thoracoplasty is a complicated, not suite explained 
proceeding. It docs not depend soleljr on a more or loss 
careful control of hemorrhage or on the extent of the 
operation. One. cannot bo sure if shock occurs more fre- 
quently in case of lattice plastic with its large wound 
surface but it is possible. Secondary hemorrhage seems 
to bo predominantly of a capillary nature. It is there- 
fore ess entail, to apply a pressure bandage after the 
o peration, 
The chief cause is a change an the composition of 
the blood and an impaired contractility of the vessels, 
t'oreoever wc have to consider the insufficient possibility 
of shrinking in the callus tissue. Sometimes one has 
the impression of a septic secondary hemorrhage. The 
blood scorns to be very poor - serous. This is 
frequently caused by a serous exudation and on account of 
change of the color of the serum it may be mistaken for 
a secondary hemorrhage. This loos of protein increases 
the danger* of a collapse or may even be the cause of it; 
but this consccucnce can be eliminated by a blood trans- 
fusion. If the general conditions deteriorates after 
the operation, one can be sure that almost regularily 
a transfusion of blood is necessary, c always acted 
according to this ooint of view and our successes showed 
that we wer-e right. There is no doubt that on account 
of the repeatedly mentioned investigations a' out the 
condition of protein deficiency in case of chronic suppur- 
ations it is possible to solve the problem of secondary 
hemorrhage after plastic closure of the empyema residual 
cavity. The osmotic pressure in the blood is changed by 
this and it can easily flow into the tissue. Toxic 
paralysis and damage of the vessles, as well as a special 
inclination towards hemorrhage can be observed here. 
As in this case too, we are dealing with the consequences 
of a chronic loss of protein, a blood transfusion is the 
only means to combat it. 
The general opinion is, that pneumonia takes the 
third place in postoperative complications. According 
to SAWROAA it will especially occur in t o stage oper- 
ations, after the first session. Incrr asc of temper ature 
was believed to have its origin in pneumonia in some cases 
wh ch proved to be wrong later on, I do not believe that a 
pneumonia exists in more than 2 cases out of a huadrod. 
Considerable and long lasting fever as a rule was not 
caused by complications in the part of the lun"s as was 
supposed first, but by an accumulation of pus. An insuffi- 
cient outflow of pus after lattice-plastic is observed 
quite freeuently. This is the most important cause for in- 
crease of temperature after the operation. 22 
After lattice plastic fever sometimes occurs 
y/hich is not caused by those two complications mentioned 
before. It is possible that it is caused by, the ab- 
normal washing oui of toxin, which is created by 
mobilization of the thoracic wall and the formation of 
soft-part ligaments. One must also think of the develop- 
ment of an infection from little foci of pus in the 
nlenral callus, where they remain untouched in contrast 
to SCHEDE’s plastic. Whatever may be the cause of this 
postoperative increase of temperature, a copious dose 
of sulfonamides as a prophylactic is recommended; 
aftertreatment 
First attention should be given to avoid the post- 
operative shock and the froeuent occurrence of scconiaby 
hemorrhage. The methods of ireatmont, which have to be 
used, were mentioned before. But this does1not clcse 
the discussion about aftertreatmentj several other points 
have to be considered; 
Immediatcly after the operation, an effective massage 
is recommended. Thus the substance, which according to 
HENDERSON stimulat s the respiratory center physiolo •• i c a"1.ly, 
becomes disengaged, and the pulse gains strength, Fresh- 
ly operated patients feel better by Improved circulation. 
It is of advantage to continue the massage every day, 
until the patient can got out of bod. 
As mentioned before, a well fitting pressure bandage 
has to be ap lied after the operation. In most cases it has 
to be renewed only after 6-8 days. A careful survey and 
observation of temperature and pulse is essential on account 
of the danger of phlegmons of the thoracic wall and the 
possibility of accumulation of pus . Even on renewal of 
the first bandages it is recommended to apoly slight 
pressure so that the strips remain well pressed against 
the pleura pulmonary. If this is not done, new cavities 
between these two parts are favored. The outflev/ of 
secretions, however, mu?t not be hindred, Sometimes it 
is not easy to find the right way betwen these two 
alternatives. It often depends on paying attention to 
the outflow of secretion, if a second operation after the 
lattice plastic will be necessary or not. 
The treatment of the wound docs not show.any pecu- 
liarities. Recovery often progresses astonishingly fast. 
In oth'r cas s the secretion of pus sometimes continues for 
a long time with inexplicable causes. The early starting 
of irrigations has to be made with every change of the 
bandage. For this purpose Rivanol has turned out well. 
The effect surely is only mechanical. It has to avoid the 
danger of even small accumulations of pus, a matter /be ch 
must not be underestimated after a lattice clastic. In 
10 to 15% of the cases abscesses occur during and even 
after the healing of the wound of operation, which break 
open spontaneously and therefore are better opened in 23 
time* In all probability they form between the stripes 
or result from little foci of pus which may exist in the 
callus of the pleura, sometimes only visible by micror 
scope. 
In cases of patients, where the secretion of pus 
continued longer than usual, we had good success by 
treating the field of operation with diathermy. This 
treatment should be taken before each renewed operation 
if the filling of the fistula by contrast medium shows 
no new development of a cavity. This method of examination 
should be used frceuently, if the healing of the wound 
is delayed, or secretion of pus continues. It often re- 
veals surprisingly romified cavities where further de- 
lay is dangerous and scraping out of the fistula is of 
no use, but only a renewed operation performed in time 
may bring recovery. 
Breathing gymnastics should be started, as soon 
as the pains of the wound ease. It can be observed in 
some cases that the lung extends: again after a lattice 
plastic. 
Exercise in moving too, has to start in time. If 
this is done, no restriction in the mobility of the arm 
remains that is worth mentioning, even after a total 
empyema residual cavity* A still more important task 
is to aveid Scoliosis, It develops always after 10HEDE i s 
plastic, but never after lattice pla tic. It is seen 
occasionally in a minor degree, but then it never in- 
jures either the functional or the cosmctical result* 
It is necessary and can be accomplished easily to 
preserve the long dorsal tensors and leave the trans- 
verse processes untouched in the operation. 
It is certain, that especially after the removal 
of an empyema residual cavity an appropriate and copious 
nourishment adds much to a quick recovery and healing 
of the wound. As we saw in this aspect of disease, the 
supply of protein is frcruently diminished by different 
influences. Therefore special stress should be laid upon 
giving food rich in protein and vitamins. 
Host generally a sulfonamide treatment is tried when 
temperature increases from possible bacterial causes, I 
do not know to what extent a treatment with penicillin 
may improve recovery faster and eliminate various other 
dangers. In case of one patient wo saw favorable in- 
fluence, In one session I had removed his right inferior 
and middle lobes on account of bronchiectases. Thereby 
a medium sized residual cavity developed, which I tried 
to remove by means of a lattice plastic. After the 
operation a long lasting suppuration with an inexplicable 
increase of temperature remained, which could not be 
decreased by treatment with sulfonamide. His condition 
weakened by bronchiectasies, lobectomy, the empyema 
residual cavity and the following lattice plastic remained 
unsatisfactory for weeks. Due to tho interest, which the 
removal of two lobes of the lungs in one session still 
has today, I was supplied with penicillin, of wh: ch 
the patient got one million units, liter this remedy 
was given, the temperature decreased and complete 
recovery followed. The success of penicillin was im pressiva, I am inclined to believe, that the use of 
penicillin, especially after lattice plastic will be 
of great value in many regards. 
According to our discussions about the value of 
blood transfusions for preparation it is understandable 
that this method of treatment is one of the mist im- 
portant remedies even in the treatment after an oper- 
ation. In case of good general condition, normal 
postoperative development and quick recovery, the body 
disposes of sufficient resources of its own. If there, 
however, is ctrong and long lasting secretion of pus, 
accompnaied by fever, the reserves of protein, already 
diminished before and after the operation ore quickly 
totally exhausted in case of empyema residual cavities. As 
the deficiency of protein cannit be supplied by parenteral 
sources alone, symptoms of deficiency of protein appear 
again. These are also displayed as we observed, by a 
decrease of erythrocytes and hemoglobin. In their 
analysis we have a valuable means to judge the pro- 
tective power of the body, or its damage respectively. 
Anaemia delays the healing of a wound. It has to be 
eliminated by blood transfusion, if the resources of 
the organism itself are not sufficient. Indication 
is based on the analysis of erythrocytes and hemo- 
globin, which must be repeated after every plastic so 
cne can perform a blood transfusion in time and some- 
times more often eiren during the after treatment, So 
we are able to cure the wounds more rapidly and gain 
faster restoration of health. 
POSTOPERATIVE MORTALITY 
Thoracoplasty to remove empyema r sidual cavities 
is connected with the idea of an operation with an 
immense death rate which in case of success leaves a con- 
siderable cosmetic deformity. This opinion is chiefly 
based on the previous experiences with SCHEDE’s plastic. 
With this method of treatment the mortality rate amounted 
to ch during the first World War, according to SAUER* 
BRUCH, In the meantime the results have been improving. 
During the last war DEMEL operated 22 empyema residual 
cavities without any casualties (cases of death). By 
the time he made his report, hoY/ever, the aftertreatmenii 
of all cases had not been concluded yet and three of 
his patients still had large bronchial fistulae. 
No notable experiences have been made yet about 
lattice plastic, SALZER and SARAFOFF only oulished 
their observations on a small number of cases. There- 
fore the quest:'on as to the mortality rate is of special 
interest in so many cases as we h.ve, considering that 
our patients could be observed until their final cure 
and even afterwards. 25 
If one imagines, that in the first hundred cases 
treated with HELLER1s lattice plastic, only three patients 
died, this fact has to be registered as an immense pro- 
gress in eliminating the dreaded aspects of disease of 
the empyema residual cavity. A mortality rate of 3% 
would be tolerable. But even this small percentage here 
is not due to the method of operation but caused bjr 
deadly complications which cannot be brought into 
definitely causal connection with the operation itself. 
This may be clearly seen in a short survey of those 
three patients who died after the plastic: 
l) A 28 year old man. On December 29, 1942 he 
received a small arms gunshot w:th the bullet 
lodging in the right thorax. A pleural empyema 
fol owed* Afterwards we had to perform a re- 
section of ribs. In spite of suction treatment, 
an empyema residual cavity developed. On July 
2, 1943, lattice plastic was made, after the 
5-9 rib had been resected* (length of ribs re- 
sected 74 centimeters). At first the post- 
operative Carrs'- was normal. On July 28, 1943 
the patient started to vomit and on 29 July he 
got headaches. His general condition worsened 
suddenly on the first of August 1943 and showed 
meningitic symptoms. He died on August 2, 1943* 
The post mortem examination showed; Pj§,£.£_. 
foration cf an older abscess in the left frontal 
i nt o_ t h e_ la t era l__y e n t r i, c 1 eA 
2) A 29 year old man was severely wounded by a 
bomb splinter in the left side of the thorax on 
August 12, 194-2, Two cavity gunshot, A pleural 
empyema developed which was treated by resection 
of ribs and suction drainage. In spite of all 
treatment, however, an empyema residual cavity 
remained. Then an abscess developed around a 
splinter below the diaphragm. Surgical exposure 
and drainage. On May 17, 194-3, another operation 
a as performed on account of suppuration below 
the diaphragm. On December 7, 1943 we made a 
lattice plastic on account of the empyema re- 
sidual cavity. Ribs 3-9 were resected sub- 
peri osteally. The length of the resected ribs 
was 87 centimeters. For three weeks the post- 
operative course was without complications or 
fever. Then a sudden increase of temperature 
occurred followed by chills. Repeated revision 
of the field of the plastic without satisfactory 
findings. Finally a large subphrenic abscess 
was opened. Septic general condition, not in- 
fluenced by any means. The patient died on 
Feburary 20, 194-4-• Rest mortem examination 
showed that the thoracoplasty was generally in 
order. It was connected with the abscess cavity, 
situated subphrenically and including the spleen. 
The diaphragm was partly destroyed. Nowhere 
retention of pus. Small abscess ~n the left tem- 
poral lobe, £ause„pjLdeatfe.l Sepsi_s, 26 
3) A 29 year old man was wounded on August 19, 
1943 by machine gun shot, which r sided in the 
right lung. A pleural empyema developed, A 
resection of ribs had to be made. An empyema 
residual cavity developed. Thoracoplasty.was 
made on July 5, 1944. 2-B ribs were reselted 
subperiosteally, Right after the operation 
considerable continuous increase of temperature 
begun. Temporary suspicion of a relapse of 
malaria. Field of operation without finding* 
On August 19, 1944 headaches and subseouent 
somnolence. On September 10, 1944 hemiplegia and 
death. Post mortem examination s owed a large 
multilscular abscess in the right frontal lobe. 
Residual cavity was closed, only a small fistula 
was found. 
Cause of death; Cerebral abscess 
If we consider critically these three pathologic© 
anatomical determined causes of death, we observe,that 
i 'no case the operation can be made responsible for 
the fatal ending. According to the post mortem examination 
the first patient had the cerebral abscess even before 
the operation, while in case of the third patient it 
probably developed after the plastic and thus caused the 
fatal end. In the second case, it was the consequence 
of the two cavity gunshot. The origin of the sepsis 
was not the empyema residual cavity, but the subphrenic 
suppuration. It is remarkable that the temperature 
of two patients was normal for weeks after the operation 
until the symptoms of the complications which caused 
the death, could be observed. 
Autopsies showed in every case that the field 
of operation was in trder or even already cured. In 
no case was a retention of pus in the thorax found 
or could any connection between the lattice plastic 
and cause of death be surely prcved. Our three failures 
have to be regarded as fatal events, as they could not 
have been avo ded with any other kind of operation. 
Far more important than this statement I regard the 
fact resulting from the short descriptions of the 
origins that caused death, that never was, not 
even in a single case, neither shock nor secondary 
hemorrhage, hitherto especially dreaded as the most 
important postoperative complication. 
With all pulmonary diseases, even after the removal 
of splinters sticking in the lung, the danger ef 
metastatic cerebral abscesr es is threatening, as they 
were found in the post mortem examination of all three 
patients who died after the lattice plastic. Sven in 
case of this grave aspect of disease it is possible 
to help by diagnosis and operation in time, as soon as 
the localization can be made. Perhaps in one »r the 
other of our cases quicker action might have been 
appropriat e, 27 
In case of pleural empyema and its seouel, raenin-- 
git is may occur occasionally besides cerebral abscesses, 
C, BAUER described two impressive observations where 
he could prove the two important ways of infection, In 
one case the suppuration had perforated from the thoracic 
cavity into the central canal »f the spinal cord. In 
my findings of operation I already pointed out the 
collection of ous in the joint between ribs and ver- 
tebral clumn. In the second case a basal meningitis 
existed. By preparation during the section its 
origin could be proved on the level with the empyema. 
The intercostal nerves were considered responsible as 
the way of infection. 
I personally observed some cases of fatal menin—• 
S±t±s in case of pleural empyemae and with empyema 
residual cavities which had not yet been operated upon. 
In the chapter ''Preparation'1 I already mentioned the 
importance which these complications as well as those 
of the metastatic cerebral abscess have on the choice of 
the time of operation, hang like thc sword of 
Damocles over the patients with empyema residual cavities 
and over the results of the surgical operations. Prob- 
ably symptoms of meningeal irritation occur more 
freouently. Before and after the operation patients 
often complain ab*ut pains in the neck and headaches, 
Fxplanations can be given by lumbar punctures, and 
various modern medicaments might sometimes prevent 
the development of a r al meningitis, it any rate, both 
cerebral abscess and meningitis require medical action 
and no passivity. Therefore, the surgeon who has t» 
do with operative treatment of empyema residual cavi- 
ties must be thoroughly familiar with these two com- 
plications and their origin. 
The three cases of death we had among the first 
hundred of our »perations wrre caused by unavoidable 
accompanying diseases. In our further cases of lattice 
plastic, mortality did not amount too much. Up to date, 
we lost two patients after the operation. Though their 
cases have nothing to do with this report, I should 
like to give a short extract because it pfoves, that 
lattice plastic alone does not succeed, but that 
greatest care is renuired to obtain outstanding 
results. 
4) A 21 year old man was taken ill on February 
2, 1943 of spotted typhus, followed by pneumonia 
and pleuritis. In spite of resection o~ 
a residual cavity remained in the right side. 
On April 25, 1945 lattice plastic was made. 
! ultilocular system of cavities with bronchial 
fistula developed. Ribs 2-8 were resected sub- 
periosteally, In the days after the operation 
the patient was strangely restless, the tem- 
perature was slightly increased, and the pulse 
moderately accelerated. He died on Mey 6, 
1945, Autopsy was impossible. 
Cause , of deat;h \ Sudden pollapse off circuXatJ4pjqA 28 
5) A 2A year old man was wounded by shell 
splinter in the right thorax on January 23, 
1945, A pleural empyema developed. We 
applied BUFLAll’s drainage system without 
resection of ribs. An empyema residual 
cavity developed. We made the lattice plastic 
on January 18, 19-46 and resected 4- ribs sub- 
peri o st eally. In addition to that was a 
gas-containing, putrid infection of the 
thorax, going down to the thigh and spreading 
there. Incision was made in vain. The 
patient died on January 26, 1946. 
Cause, .of death; Failure .of circulation. 
In case J+, the cause of death is obscure* After 
the extensive thoracoplasty neither shock nor second- 
ary hemorrhage was observed. In the days following the 
operation the patient showed a strange motor restless- 
ness, Possibly external influence effected the 
patient unfavorably. After the operation the patient 
had to be moved to a hall were many prisoners were 
crowded together. Our trained staff was not allowed 
to take charge of the nursing upon which so much 
depended. We used to place all the other patients 
with thoracoplasty in small, single, and w~ll aired 
rwoms. Perhaps the basic (original) disease may be 
traced as the cause of death, I observed several 
times that patients who had serious spotted typhus 
could generally not starid major operations very well. 
Finally the fact that the residual cavity had al- 
ready existed for two years may have been of in- 
fluence, It is regrettable, that in this single 
case, where death was probably solely due to the 
lat ice plastic, we were not able to perform an 
autopsy. Perhaps in this case too, a cerebral 
abscess caused the fatal end. 
The cause of death is very clear in the fifth 
case. Being exhausted aft-r finishing the plastic, 
I ordered an experienced assistant to finish the 
operation by some sutures. Against my strict orders 
he sewed skin and muscles near the drainage tube and 
the striae so tightly that the secretion could not drain 
out and therefore a gas-containing phlegmon of the 
thoracic wall developed, which caused the death. This 
case shows, that success often depends upon trifles 
in technioue and greatest care in the aftertreatment. 
This robust patient could almost surely have survived 
the small plastic if this mistake had not taken place. 
Summarizing the causes of these five death once 
more, we must state that the lattice plastic is with- 
out special dangers. The mortality rate is low, 
compared to the gravity of the disease. If a patient 
dies after the operation, this is nearly always an 
inevitable event, if no unavoidable mistake has been 
mad©. 29 
THE RESULT OF THE OPERATION 
Judging the results of the operation we have to 
consider several points of view. The duration of 
treatment after the lattice plastic reveals clearly 
the usefulness of the method. patients re- 
covered so rapidly, that they could be discharged from 
the clinic within U weeks after the operation. Most 
4f the patients, 4-3 exactly, hald to stay in the hospital 
for 8 weeks, 22 for 12 weeks, 12 for 16 weeks and the 
rest even longer. Though in some cases suppuration 
occasionally continued a long time, the period of 
treatment after the thoracoplasty is generally short. 
It cannot be explained what causes the great differences 
in these cases. 
There is a certain disadvantage in the later develop- 
ment of abscesses in the field of operation* The 
wound of one patient had been healed for 9 months al- 
ready, This late complication could be observed in 
12 patients. After drainage, the abscesses generally 
healed without difficulty. They start from small foci 
of pus which have apparently remained in the field of 
the plastic, or exist in the cal1us itself. Sometimes 
small residual cavities develop which may even require 
a secondary operation. Ai any rate the probability 
of a later development of abscesses is so great, that 
patients should be informed about this possibility, or, 
even better should be asked to come to secondary 
examinations periodically. 
By exact inouiry we are able to find out with cer- 
tainty the cases where the wound of operation had healed 
externally but inflamraed f©ci existed underneath. The 
sedimentation of the blood corpuscles may be normal, but 
the red blood picture gives better information. A slight 
anemia means toxic damage and thereby the existance of a 
suppurative focus. According to our experience the 
best means of finding out consists in watching the general 
condition of the patient and in asking himself. In- 
creasing weight after the thoracoplasty is a very favor- 
able ©men. The same holds good with regard to the 
appetito, 1f the patients compl&in about anorexia, in- 
sufficient convalescence, bodily weakness, or easy fatigue, 
one can be sure of a suppurative focus in the body. 
As a proof I should like to ad an instructive ob- 
servation. After the thoracoplasty one patient com- 
plained about the above mentioned troubles. An abscess 
formed, which was incised. But even after healing the 
patient still complained and the bad general condition 
remained, I therefore reopened the field of the former 
abscess and found a small hidden empyema residual cavity. 
To find such hidden foci renuires experience in this 
field and some luck. After two ribs respectively their 
regenerates had been resected subperiosteally, the focus 
healed quickly. This was followed by excellent recovery, 
good appetite, increase of weight, and a decided improve- 
ment of productive power. As my experiences proved 30 
impressively in such cases one should not hesitate to 
perform a secondary operation, even after an apparently 
successful plastic. In no case have 1 ever regretted 
a secondary operation. 
But the following oase proves that caution should 
be taken: A patient did not recover well after thoraco- 
plasty, It was suspected that a suppurative focus 
had remained in the thorax and a secondary operation 
was taken into consideration. indications for a 
second operation were not entirely fulfilled, so we 
desisted from it. Finally another cause for the symp- 
toms of disease was found. After nine months, a 
lymphogranulomatosis developed on ace out of which the 
patient died soon afterwards. 
Not every abscess developing afterwards should be 
regarded as a consecuence of lattice plastic. Visiting 
another hospital once I was shown a patient whom I had 
operated before and who was said to have a relapse 
respectively an abscess in the field of operation. 
The fil ing of the fistula revealed, that the suppuration 
had nothing to do with it but was caused by a shell 
splinter which was not removed in the operation 111, 15, 
In the case of another patient in our- clinic, wo had to 
remove a shell splinter two years after the plastic, 
because of symptoms of inflammation, Missiles generally 
heal in without complications. As the plastic is no 
simple operation, we do not se~k for thorn. If the 
splinter is easy to find, it should be removed to avoid 
another operation, as happened in the two cases mentioned 
before, 
By careful after treatment and good food we are able 
to avoid the danger of a renewed collection of pus in the 
field of operation. The small foci of inflammation 
between the striae or in the callus heal auickly, if the 
power of resistance of the body grows strong enough, I 
saw some impressive cases, myself, which proved this in- 
directly, After a successful thoracoplasty and discharge 
from the hospital, one of my patients was taken prisoner. 
He had to stay in an open field for weeks without suffi- 
cient clothing and food. This caused an inflammation 
in the field of operation connected with a marked suppur- 
ation, In case of another fully recovered patient who 
was not operated in my clinic, I observed a similar re- 
lapse, Several operations had oroceeded4 After some 
week’s stay in the oepn with insufficient food which 
caused death by starvation of many soldiers, a secretion 
of pus from all scars in the field of the thorax began to 
an extent I had never seen before. If one has met with 
such negative cases, one can easily estimate the value 
of good food during the after treatment, which should be 
given after every cured thoracoplasty. 
Contrary to cases where late abscesses develop after 
the patient was discharged from the hospital, it some- 
times occurs that the healing of the lattice plastic 
is delayed, or even a residual cavity remains, kith 
5 patients we did not succeed in obliterating the re- 30a 
Illustration 1$ 
Shell splinter, causing an abscess one year 
after the lattice plastic. At first the 
abscess was regarded as a consequence of the 
thoracoplasty. 31 
sidual cavity with one operation, but had to perform 
second operations, 8 of our patient had a plastic 
before by another surgeon, I intend to discuss these 
13 cases in another chapter as naturally the causes of 
these failures and the ones of the secondary operations 
must be examined very carefully, to find out if they 
were based on avoidable mastakes. 
To judge a new method of operation, not only the 
immediate but the lasting result is important. We 
therefore tried to watch our patients even after their 
discharge from the hospital. The months following the 
discharge we succeeded in doing so. Nearly all of them 
came back for a late examination or otherwise were sent 
to us. About 90% of the patients reported to us the 
seouel of the operation during the first following 
year and sometimes even during the second one. On 
account of -the influence of war we were not able to 
obtain complete reports, but the particulars we have 
are sufficient for our purpose. In several chapters 
we already stated some interesting observations about 
diseases after the lattice plastic. Little can be 
reported about consecutive disease. To our surprise 
we never found an amyloid kidney. In the case of one 
patient a nephrosis developed several months after 
discharge from the hospital; freruent tests of urine 
before and after the elastic had shown a negative 
finding for albumin. With another pat?out an exo- 
phthalmic g• itre developed, the cause of wi ch was 
probably favored by the preceding long period of suffer- 
ing. 
Some patients showed an inclination* towards 
bronchitis. In one case with a total plastic only 
it was purulent and could not nuite be cured* It is 
astonishing, that after an often extensive collapse 
of the lungs and the distinct formation of callus this 
■ 
complication does not occur more freouently. fhst 
patients stated in the late examination that they felt fik 
for wofk again* A very freouent Complaint was shortness 
of breath. Reduced productive power was only stated 
by patients with total plastic, especially one in thb 
right side of the thorax. Contrary to this, patients 
with partial plastic regained their full strength 
after months and sometimes even after years of having 
suffered the greatest hardships and bodily strain. 
It is not easy to judge the protective power 
after the lattice plastic. If the surgeon is asked 
to do it, he predominantly must rely on the statement 
of the patient, as is to be seen in the discussion of 
the success. If possible, a spiro.graphical examination 
should be made. 
One of the most important advant:, es of lattice 
plastic compared with SGHEDE's plastic, is, th?.t with 
the first one mentioned n# paradoxical respiration 
remains. One could draw the conclusion, that the lungs 
functioned better. AMFLUNG performed spirographic 
examinations but did not find any basic difference 
between the two methods. We must st .te on the otker 
hand, that the number of cases examined is too small 32 
to be fully convincing. Clinical experience in cases 
observed for years is against it too. Therefor- a re- 
newed examination is desirable. 
Most striking is the cosmetic result. After 
SCHEDEls plastic severe mutilations of the thorax re- 
main. This is not the case in lattice plastic, as 
shoulder girdle, and shoulder blade the fjrst and usually 
the second rib arc preserved and no scoliosis develops 
if the after treatment is carefully done, (111, 16)* 
Another highly important advantage is the preservation 
if the Intercostal nerves. Therefore no paralysis of 
the muscles of the abdominal wall occurs which has an 
unfavorable influence on the work capacity after SCHEDE’s 
plastic* According to OEHLECKER*s examinations, even 
the sixth intercostal nerve has to be preserved. KON- 
JFTZNY also has lately tried to preserve the intercostal 
nerves in his plastic. 
REPEATED THORACOPLASTIES AND SECONDARY OPERATIONS 
Unfortunately lattice plastic does not in every 
case result in the obliteration of the empyema residual 
cavity, A second thoracoplasty was necessary in case 
of 5 patients, whom I had operated myself. In our 
hospital we have 8 other patients who had had an un- 
successful thoracoplasty-which was not made in our aline - 
before. It is highly essential to examine the causes of 
those failures, because one can learn best by one’s own 
and other’s mistakes. 
Among my own failures one can observe me case, 
that clearly and impres sively shows one disadvantage of 
lattice plastic. On a 16 year old boy, 5 months after 
the resection of ribs, we had to perform a lattice 
plastic on account of a metapneumcnic pleural empyema 
to remove a small residual cavity. However, we did 
not succeed. Three more plastics, partly according 
to HFLLE, partly to SCHEDE and the removal of the 
transverse processes were necessary t# gain a final 
result. After the first secondary plastic a large 
cavity had developed again, which caused suppuration. 
This result was miraculous, as no technical mistakes 
had been made in the first operation and the striae filled 
the cavity well. 
At last we succeeded to obtain a cosmetically and 
functionally good result. But difficulties and relapses 
caused us to reflect. How was this to he explained? 
I rendered special attention to this ouestion. According 
to my experiences up to now it is based on a cu'ck power 
of regeneration of the periosteum of ribs which is especially 
expressed in young people. In this age, it takes a 
short time to form new ribs. If a suppuration develops 
after lattice plastic and the st'iae do not stick to the 
surface of the lungs, the ligaments of the soft parts be- 32a 
Illustration 16* 
STosraetic and functional result 
after lattice plastic in a total 
residual cavity, 
a)X-T0.y picture of the res5 dual 
cavity 
Illustration 16 
b, c, 
could not be reproduced with 
the facilities available. 
Condition after plastic with Picture from the front, 
preservation of the first 
and second rib. 32b 
Illustration 16, 
a y e 
could not be reo»oduced with 
the facilities available. 
Illustration 16 
Picture from the side, '96 
Picture from behind. 33 
come bulky and finally stand off in such a way, that 
once again large cavities can develop beneath* them; 
The cuick development of regenerated ribs is also a 
cause of long lasting fistulae and sometimes even 
secondary operations as wo shall see* 
It should be considered therefore, if the power 
of regeneration of ribs should be stopped or delayed as 
is done similarily in ca.se of thoracoplasty, because 
of tuberculosis of the lungs* The problems are ruite 
the same as those with empyema residual cavities* 
MAURER uses a 10b solution of formalin for this pur- 
pose , MEISS proved by experiments that the regenerate 
tten power of the ribs can thus be delayed, without 
damaging the pleura. Up to now I could not resolve 
to use his met' od, although it is said, that it does 
not influence the healing of the wounds unfavorably* 
According to LOUBAT and MAGFNDIE the regeneration of 
ribs can bo delayed for 2 to 3 months, by spreading a 
solution of tannin over the periosteal tubes, which 
means, that the tissue has time to shrink. However, 
this proposal has to be examined, because SAUERBRUCH 
states, that the retraction of the lungs continues for 
2" to 1 year, and that the ligaments formed by the 
lattice plastic stay limp and flexible for a long time* 
The second cause can be traced back to an ab- 
normal stiffnc s of the striae. It can be observed 
especially in case of a strong development of callus. 
It is understandable, that SALZER prefers the tcchnieue 
according tfc SCHEDE, if the pleural cal us is thicker 
than 2-k centimeters, When using this method one sacri- 
fices valuable mat rial for filling. To increase the 
flexibility of the striae under such circumstances and 
to obtain a good filling of the cavity, I lat ly have 
removed the callus tissue, especially at the inside of 
both places whore the striae are attached. So the li- 
gaments become bettor attached, even if the pleura 
is markedly thickened and one has the impression that 
a new development of a cavity can be avoided by elimi - 
noting the unsuitable shape of the filling material. 
The two first sources of mistakes w e based «n the 
method itself, which does not apply to the twfx other ones, 
The third cause is failure tt Observe 'accessory cavities 
which many times arc connected only by a small fistula 
with the main cavity. This danger can bo avoided only 
by greatest caution and experience. One should not under- 
estimate it. The fourth mistake is favored by the 
tendency to make the plastic as small as possible. 
Thus, either too small pieces of the ribs, lying over 
the cavity are removed, or not enough ribs will be re- 
sected, In case of a patient we had to remove 2 more 
ribs in the field of the first plastic done in one 
session because pus had collected behind them like a 
lake. In the first session wr had the impression, that 
the conditions for the outflow of.pus would be favor- 
able, I have observed this same event several times lately. 
This is apparently favored by shrinking of the lungs after 
lattice plastic, where the ribs below, which have been 
preserved, cause retention of pus or development 34 
of cavities by interception which were not expected 
according to the findings at the time of the thoraco- 
plasty; On a cured patient one can sometimes observe an 
abnormal standing out of the lower costal arch and the 
preserved ribs below the field of the thoraco plastic, 
by which this occurrence might easily be explained. 
In case of 4 other patients wo were, not to mention 
an occasional scraping out of fistulae, forced to per- 
form secondary operations, which cannot be called 
secondary plastics according to their extent. In 
one case a small abscess cavity developed b'neath a pre- 
served rib. In other operations we had to remove regene- 
rates of ribs, which prevented the falling together 
in the depth bjr the thick callus tissue. Under these 
circumstances the callus cannot shrink sufficiently and 
thus supports the cavities in its field. For fistulae 
and suppuration which often remain for a long time, the 
same causes have to be made responsible as the ones 
leading t# the development of largo cavities, ?/hich 
sometimes recuire another plastic. Furthermore the 
possibility has to be taken into account that small 
»us and inflammation foci arc i n the pleural callus 
which can lead to a secretion of pus or formation #f 
fistulae after a lattice plastic. Therefore it 
should be considered, . in case of thick callus 
whether part of them should be removed at the inside 
of the ligaments and thereby eliminate the changed, 
most inflammable field, I tried this in some recent 
operations without up to no?/ being able to say anything 
about the final result. The preservation of the 
thickened lateral callus of the pleura and its use for 
filling out the caVity does not only have advantages, 
but disadvantages too, but without doubt, the advantages 
generally prevail* 
This discussion reveals, that after a lattice plastic 
one cannot depend on too much success if fistulas are 
scraped out* If secretion of pus continues for some 
time, it is recomrended to clear the canal of the fistula 
for comprehensive view, (111* 17)* Sometimes it is 
possible by meats of X-ray of the fistula which should 
precede each operation, to find at its end in the depth 
of the thoracic wall a cavernous enlargement, sometimes 
even an osteomyelitis of the ribs or a secuestrum of 
bones which are the catse, The origin of the pus has to 
be removed and by re laxat ion of its callus thickened 
surroundings the focus of disease must be enabled to 
close by shrinking, which sometimes is rather difficult. 
Though fistulao existing for a long time may close them- 
selves and little cavities of pus encapsulate in depth, 
I nevertheless advise an active attack. Lately I have 
performed more frequent operations and up to now I have 
never regretted y more energetic action. 
The eight thrracoplastics, of which the first ones 
had been performed without success i n another clinic 
do n#t have the same importance as our o?/n observations, 
as one cannot foil#?/ fhe procedures by reports about 
findings and soouel especially in case of operated 34a 
Illustration 17 
Could not be reproduced with 
the facilities available. 
Illustration 17 
Filling of a fistula with renewed formation 
of a cavity after thoracoplasty. All stumps 
of ribs were left too long empyema residual cavities. We therefore should be 
careful with our criticism. With 2 of these 8 cases 
a lattice plastic had preceded. With one patient , 
who had a total residual cavity, wo tried to close it 
by an extended subperiosteal resecti of the first 
- to third rib, removing the transverse processes at the 
same time. Thus the cavity diminished a little, and could 
only be eliminated by a lattice plastic. This com- 
bination of the methods of FSTLANDRR and sometimes 
is justified and saving. Apart from this case I saw 
several other patients thus operated in two sessions. 
But a repeated resection of ribs reauires considerable 
strain. Two other secondary plastics were caused by 
costal osteomyelitis. Besides this not enough ribs had 
been removed and furthermore the pieces of the ribs 
removed were too small. 
In case of the remaining 5 patients, the posterior 
back stumps of the ribs had been preserved in abnor- 
mal length as we can see in 111, 17, This is a most im- 
portant but avoidable mistake, which can occur in case 
of surgical removal of the empyema residual cavity, if 
the basic rules of thoracoplasty are not generally known, 
BOIFFIN through his student GOURDE! proved already in 
1895 with excellent examinations which are still of value 
today, that the compression of the thorax can be best 
accomplished by removing the posterior angle of the ribs, 
SAUFRBRUCH and BRAUER always point d out the importance 
of paravertebral resection of ribs for the collapse of 
the lungs. It is understood, that for the treatment of 
tuberculosis of the lungs one has to have exact know- 
ledge of the numerous surgical proceedings which ho has 
to know too for the removal of empyema residual cavities. 
Setting aside this technical error, wr must summarize 
that only one important avoidable causa for the failure 
of thoracoplasty and its repetition can be made respon - 
siTale: Too small an amount of the resection of ribs or 
the removal of not enough ribs. Though one endeavors in 
every plastic to render the operation as preserving and 
small as possible, one should always face this fact in 
every plastic, lattice plastic as well, and the removal 
of empyema residual cavities 
CONCLUSION 
If one occupies himself thoroughly for years with 
empyema residual cavities, and operates far more than 
100 patients with a method scarcely known hitherto, one 
should like to discuss points of view which seem to be 
important in special chapters. It could,however, not 
be avoided, to state some remarkable facts in different 
chapters before. Concluding this, I should like to 
point them out and show their importance. 36 
First of all wo have to mention the blood transfusion. 
Its value is increasingly acknowledged 5n case of pleu- 
ral empyema and its sequelae* K* VALENTIN pointed out 
that since taking up this method of treatment for pleu- 
ral empyema in juvenile ago, the mortality rat© rapid- 
ly lowered* The false doctrine, prevailing for a long 
time, that blood transfusions, used for diseases in the 
field of the pulmonary circulation was a mistake, seems 
to be abandoned. Blood transfusion can in no case be 
eliminat 'd for the preparation of the ope ation of emoyema 
residual cavities, for fighting postoperative shock and 
for the after treatment after the operation* Its <• roa.t 
importance can be understood fully, if one deals with 
the problem of the disease of protein deficiency, which 
may be fatal in case of pleural empyema. Such great and 
import ,nt progress in the theoretical and practical way 
has never been obtained in any field. Owing to this a 
reference to the methods, concerning blood 
which is scattered over some chapters, seems to be useful. 
The use of X-ray examination telcos a special value 
for judging the rmpyema residual cavities. It is asso- 
ciated with several sources of mistakes. Pictures 
must always be taken from two sides. The cavities are 
regularly larger :• n the operation than they appear in the 
X-ray picture. Accessory cavities are usually not to 
be seen at all. An X-ray picture may give full information 
on fistula after plastic, 
The discussions of numerous special and rare aspects 
of disease should be of great interest, .The closed re- 
sidual cavity v;ithout bronchial fistula is not very well 
known, but the hemothorax residual cavity, recently des- 
cribed by me, is entirely unknowh. In case of three 
patients empyema residual cavities have been discovered, 
which had boon operated later on* ;ihoy had 7, 11 
respectively 25 years before suffered from pleural empyema 
and after having had a resection of ribs, an ostensible 
recovery had been obtained during such long ncri-pds of 
time. All these observations show that the empyema resi- 
dual cavity offers oven clinically many interesting 
problems, but as we deal almost entirely with technical 
operative ouostions in th^s volume, we have to renounce 
the discussion of the oth~r problems. 
SUMMARY 
Aft r having critically discussed the so far used 
methods for removal of the empyema residual cavity, wo 
should like to to the new Procedure «f lattice 
plastic which, after having the experience of 150 oper- 
ations with a low mortality rate, enables us, to close 
every residual cavity with excellent cosmetic and function- 
al results. In this volume we described the observations of 
•ur first 100 plastics of which 71 were partial and 
29 total cavities. 36a 
a 
State before the second 
thoracojilastlc • Empyema 
residual cavity is filled 
with Thorotrast, 
b 
Findin:'t: after success- 
ful second thoracoplasty 
with removal of the 
posterior stumps of ribs. 
Illustration IS 
Abnormally long posterior rib stumps 
as cause of unsuccessful thoracoplasty. 37 
The cause of the empyema residual cavity was 
responsible 27% due to a mistake in the drainage, in 
25% by too long continued puncture and rinsing, in 
IB/o by a closed residual cavity, in 16% by a bronchial 
fistula, in 6% by an osteomyelitis of ribs, in 3% by an 
acce sory cavity, in 2% by bad gen*ril condition and in 
1% by a foreign body, while tuberculosis has been dis- 
covered in 2 patients later on. Such changes may happen, 
and for that reason cxploratary excisions should be taken 
before each plastic. 
Treatment with strong suction should be tried before 
each operation. The time for the operation has arrived, 
if the X-ray picture of the residual cavity shows no 
decrease in size of the cavity over 4--S weeks. 
The preparation f»r the operation is of great im- 
portance* First of all wo have to take care of an ex- 
tensive detoxication, furthermore all damages caused by 
chronic suppuration should be eliminated* Very fre- 
ouently a protein deficiency is present which cad be 
detected in the changes of the blood; in which case a 
blood transfusion is necessary. 
The lattice plastic should be carried out with local 
anaesthesia. This can be done in about 90% of all cases, 
sometimes a slight ether anaesthesia in addition is 
necessary. 
Sometimes a combination of HELLERand SCIIEDEis 
plastic has te be considered. In cases with thic1: and rigid 
callus we recommend to excise some parts of the inside, 
especially at the insertion point, to male the strips more 
flexible. Only once I had to resect the apex of the 
scapula. Bronchial fistulae do n»t rceuire special 
methods of treatment in case of lattice plastic and 
usually heal by relaxation. Only twa patients wore 
operated in two sessions. With total cavities we always 
can preserve the first rib and sometimes even the second 
one. The lung tissue always shows good recovery after a 
lattice plastic. To judge the danger of the operation it 
is necessary to give number and length of the removed ribs. 
Shock and secondary hemorrhage were the most important 
postoperative complications before. They can be avoided 
by immediate blood transfusion after every plastic or in 
the course of the after treatment, and by experienced 
treatment do not end fatally any more. The knowledge of 
the protein deficiency contributes essentially to its better 
und o r s t a nd i ng, 
After lattice plastic the further after treatment is 
very important. The effect of an immediate start of 
massage is favorable. Breathing gymnastics, exercise in 
moving the arms and the vertebral column have to start as 
saon as posible. Blood transfusions too, have to be con- 
sidered freouently. The treatment of the wound roruirss 
special care, sometimes rinsing. 38 
The mortality rate was 3%. No death was caused 
by the method of operation. There was a discussion 
about metastatic cerebral abscesses and the danger of 
meningitis * 
The time for treatment reouired after the operation is 
usually very short. Quite freouently late abscesses 
develop in the field of operation. Sometimes foci of 
pus remain in the depth. The general condition, appetite 
and increase of weight are more important for the judgement 
than the blood picture and bloo£ sedimentation rate. 
One should not be hesitant about secondary operations. 
The permanent result of 90% of all patients who have been 
operated has been followed for the first six months after 
the operation and by others even for several years. The 
functional ability can be discovered spir•graphically, 
The advantages of HELLER*s plastic, compared with SCHEDE*s 
plastic are: No remaining paradoxical respiration, no 
paralysis of the abdominal wall, excellent cosmetical 
and functional result* 
The plastic did not lead to any results in case of 
5 patients. The cause was clue to the method* The failure 
depended upon too quick regeneration of ribs, abnormal 
stiffness of the strips in the thick pleural callus, 
overlooked accessory cavities and t»o small an extension 
of the plastic. 
Besides this, 4 secondary operations were necessary 
in order to dry out long lasting suppurations. The causes 
were similar to those of the secondary plastics. 
The causes of the failures of 8 residual cavities, 
operated outside of our hospital were mostly abnormally 
large posterior stumps of ribs, or a too small extension 
of the first plastic. An osteomyelitis of ribs occurred 
twioo, 
Concluding I should like to point out the exceptional 
position of the bl»nd transfusion in preparing the oper- 
ation and in the after treatment as well as X-ray 
examination. Some special pictures of the momentary 
state in case of empyema residual cavities are displayed. 
It might be important to know, that vrith no patient, 
hospitalized in our clinic has a plastic been refused 
or not been carried through. 39 
LITERATURE 
ALEXANDERj Johann Chronical suppurations 
of the pleura at first 
trivial, later proving 
to be tuberculous. Arch, 
med* chir, Appar,resp*8 
1-10, 1933 
AMELUNG Aspect of disease of a man 
shot through the thiraX, 
proposals for treatment 
in the homeland. Arch, din, 
Chir* 206, 144-170, 1944 
AMELUNG and A4MEYER The clinical importance of 
spirographie, its special 
use as pulmonale and car- 
diale examination of func- 
tional ability in case of 
patients shot through the 
lungs, Beitr, Klin, Tbc, 
BAUER, Curt Treatment and complications 
of pleural empyema©. Arch* 
din. Chir. 168, 269-283, 
1931 
BEHREND, Albert Specially chosen part- 
plastic of the thoracic wall 
and pedunculated muscle 
flaps in the treatment of 
chronic- suppuration of the 
pleura. Surg. 72,87-91,1941 
BERNHARD, Fr, The surgical treatment of 
the empyema residual cavity, 
Zbl, Chir. 194-3, 1802-11 
Late consequences after shots 
through the lungs and their 
surgical treatment, 
Zbl. Chir. 1944-, 17-23 
The haemo-thorax residual 
cavity,(Eelng printed). 
BISGARD, I.D, Ribs lying above the empyema 
residual cavities, A 
pathological study. Arch, 
Surg, 27, 94-1-959, 1933 
CHAXIR, Ahif The treatment of empyema 
residual cavity of children 
by muscle flap after re- 
section of the scapula, 
Zbl.Chir.1937, 1470-1471 uo - 
DEMEL, R* The importance of a radical 
surgical operation in time 
in case of post-traumatic 
empyema residual cavities 
of the thorax, Zbl, Chir, 
1944-, 159-162 
DUESBFRGj R, Blood transfusion as paren- 
teral suvs . itu.ti on of pro- 
tein with protein loss due 
to suppuration of heiaor. 1- 
rhoge, lin, '.rschr, 1943 
FGGERS, Carl The radical operation of 
the chronic empyema. 
Annals of Surgery 77, 1923 
337-353 
, The chronic empyema, etiol, 
path* compl. treatment and 
results (Duration)* Ann* 
of Sung. 77, U2-170, 1923 
PICK, W. Clinical experiences, lately 
observed, about procedure 
and treatment of the 
pleura empyema, Med, Klin, 
1939, 460-464- 
FROLOV, V. About a case of phrenico- 
tomy with an old empyema 
of the pleura. Ref, Z.0, 
38, 57$ 1927 
GAY, Fr, and CLARK, A.R. About the mode of action 
of sulfonamides on the 
experiment.'.! streptococci 
empyema, Journ. of cxncr, 
Med. 66, 535-548, 1937 
HELLER Prophylaxis and tr'atment 
of empyema residual cav, 
Chir. 1934-, 297-302 
KJAER, Taye Treatment of chronic suppu - 
r.otions of the pleura accord, 
to ROBERTS. Red.Z.Org.104-, 
78 (194-2) 
KLEINSCHMIDT Operations of the thorax 
and thoracic cavity, -IRSCH- 
NER* s doctrine of opcr, 
Verl, Julius Springer, Berlin 
194-0 
KONJETZWY, G,F, Special conseruences of 
rubber tubes remaining in 
pleura empyema residual 
cavities. Chir, 13,1-6,194-1 
To the prognosis of shot 
wounds of the lungs, 
Mitteil-v, d. Grenzg, Med, u,G hir, 
33, 1918 41 
KRAMPF Surgical treatment of the 
empyema residual cavity 
Zbl, Chir,1935,1211-1215 
KRAUSS, H, Late conseouences after 
shots through the lungs, 
Ther.d, Gegenw,1944,H,3/4 
LANDOIS, F* Ins The surgery of EIP-aGHNeR 
and NORDMANN. 2,Aufl,5.Bd. 
LAVR00N Postoperative pneumonia in 
case of unilateral plastic 
of the thoracic wa11, 
Ref.Z,Ora. 107, 261,1942 
L0UBAT and MAGENDIE The retarding effect of 
tannin on the new formation 
of bones in case of a 
plastic of the thoracic wall, 
47,Kongr,Franz,Chir* 821-828 
(1939) 
MAURER, 6, A combination of a lung 
collapse method for treat- 
ment of cavities, 
Benno Schwabe, Basel 1942 
MEADE, Richard H, Recurrent purulent inflam- 
mation of the pleura. 
Am. Surg,101,559-567, 1935 
MEISS, W,C, Experimental contribution 
to the simplification of 
thoracoplasty in several 
tempi, Zbl,Chir.1930,349-54 
NEVILLE, I.V.H, The treatment of the chronic 
suppuration of the pleura 
with continuing high negative 
pressure, iurg, 69,240-24-6, 
1939 
NICHOLSON Intra pl~ural treatment 
with sulfonamides of the 
streptococcic ompycma, 
Brit,med,Journ,1933,115-17 
OEHLECKER Lateral pseudo hernia after 
costal shot fracture with in- 
jury of the intercostal nerves 
. Partical paralysis of 
the abdominal wall in its 
relation to the surgery of 
the thorax, 
Dtsch.Z .Chir. 157,93-140,1920 42 
SALZER, Georg Prophylaxis , and treat- 
ment of the empyema r sidual 
cavity, Mittl.Grenzgeb, 
Med,u,Chir,46,122-38, 1942 
SARAF0F Arch.klin.Chir. 194,558,1939 
SAUERBRUCH The treatment of the suppu - 
ration of the pleura. 
Arch,klin.Chir,157,235-80 
1929 
SCHLEGELj M, Treatment of empyema by 
blood transfusion. Eschr, 
K i nd c r he i Ik, 64,3 2 9 -3 6,193 6 
SCHNEIDER Fff/ct of toxin of foul 
pus :n case of pleura 
empyema. 
Dt sch,Z sc hr,0hir,244,521-30 
1935 
VALENTIN, Karolino Treatment of ploural empyema 
in juveniles. Arch. inderh, 
126, 190-193 1942 
VOSSCHULTE, K, Disturbances and diffi- 
culties in the treatment of 
suppurations of the pleura, 
Mucnc h.raed,Wsc hr.1943, 50/51 
WACHSMUTH The cachexia of wounds 
caused in the war, A symp- 
tom complex caused by in- 
fections and loss of protein, 
V er o e f f o nt 1. C hir S o n, La z , 
O.K.H. 194.2/4.3 490-495 
WANGENSTEEN Plastic of pedunculated 
muscle flap for closing of 
existing bronchial fistulae 
of the pleura. Description 
of preservation and use of 
the intercostal muscle-bund- 
le by forming lie a ents 
(on account o f avo:■ d:■ ng a 
phrenicotomy)for closing 
large chronic thoracic 
cavities. 
J,Tborac,Turg, 5,27-53 and 
76-82 (1935) 
WESTHUFS The obliteration of large 
empyema residual cavities 
with bronchial fistulae, 
Zbl.Chir. 1942,1572-78 43 
ZSCHAU About the applicability of 
pedunculated muscle flaps 
in operations of residual 
empyema*and indirect bron- 
chial fistulae, 
Zbl.Chir.1939,2529-2534