Schede's Operation for an Old Empyema; 
Cathcart's Drainage; Recovery. 
A PAPER READ BEFORE THE SURGICAL SECTION OF THE 
COLLEGE OF PHYSICIANS, APRIL 9, 1897: • ' - - 
w. w. keenJm.d., 
Professor of the Principles of Surgery and of Clinical Surgery, Jefferson Medical 
College, Philadelphia.** 
REPRINTED FROM THE THERAPEUTIC GAZETTE, MARCH, i8gS. 
DETROIT, MICH. ! 
WILLIAM M. WARREN, PUBLISHER. 
1898. SCHEDE'S OPERA TION FOR AN OLD EM- 
P YEM A; CA THCART' S DRAIN A GE; 
RE CO VER Y. 
By W. W. Keen, M.D. 
J. F. S., aged twenty-four, was sent to the 
Jefferson Medical College Hospital by Drs. 
John and George Potteiger, of Hamburg, 
Pa., December, 1895. His family and per- 
sonal history are negative, excepting that at 
twelve years of age he had an attack of 
chorea, which lasted for a year and recurred 
slightly a year later, but has never returned. 
In April, 1895, between eight and nine 
months before his admission, he had a left- 
sided pneumonia followed by pleurisy with 
marked bulging of the precordial region. This 
was incised, and drained on May 30. A 
second incision was needed at a later date, 
and a third about the 1st of August. On 
admission there was no healthy breath sound 
over the entire left side of the chest. The 
left chest wall was considerably flattened, 
especially at the upper portion. The apex 
of the heart was displaced two inches to the 
right. Specific gravity of urine 1.032; neither 
albumen nor sugar. 
Three sinuses still existed at the point 
where the incisions were made (Fig. 1). 
Evidently the attempt by Nature to cure by 
approximating the chest wall had not suc- 
ceeded by reason of the rigidity of the chest 
wall. This, from the long-continued sup- 2 
puration, I deemed to be probably due as 
much to the thickened pleura as to the ribs. 
Operation December 4, 1895. I first made 
an incision connecting the various sinuses 
and removed the diseased tissues around 
these apertures. An opening into the in- 
terior of the chest was found between the 
fifth and sixth ribs just in the nipple line. A 
long probe reached upward as high as the 
clavicle, downward to the diaphragm, and 
backward to the posterior wall of the chest. 
A long curved incision was made extending 
from the first incision to the scapula. The 
flap covered most of the side of the chest. 
The incision was made directly down to the 
ribs, and all the soft parts external to the 
ribs were lifted. Beginning then at the open- 
ing into the chest cavity, by a large pair of 
bone pliers I divided all the tissues of the 
chest wall up to, but not including, the second 
rib, downward to the diaphragm, and at the 
upper and lower extremities of this incision I 
divided the entire thickness of the chest wall 
well back under the anterior edge of the 
scapula, and vertically between the ends of 
these last, thus removing the wall of the 
chest (except the flap) from the third to the 
eighth ribs inclusive. The pleura was nearly 
an inch thick and its cavity was filled with 
pus. The left lung was obliterated and 
bound to the inner side of the apex of the 
left chest; the pleuro-pericardium forming a 
vertical diaphragm about an inch inside the 
nipple line. The entire surface was curetted 
and lightly packed with iodoform gauze. The 
flap was then sutured in position, except at 
an opening below for drainage. My inten- 3 
tion in suturing the flap except a small drain- 
age opening was to obtain its adhesion to the 
soft parts as far as I could. I then intended 
in three or four days to cut the sutures at 
the apex of the curve so as to get more room 
for drainage and packing; especially would 
the drainage be good when he was in the 
erect posture. No trouble was experienced 
with hemorrhage. The bone forceps appar- 
ently arrested the hemorrhage by crushing. 
The ribs were adherent to each other. 
Fig. i. 
After the operation his temperature fell to 
95.6°, but by the fourth day had gradually 
risen to 102.20. On the sixth day it had 
fallen to the normal and remained so till he 
was discharged. 4 
I found, after the first few days, that the 
abundant suppuration in the old cavity of 
the pleura was not freely drained by the 
gauze, and accordingly I applied the appara- 
tus of Mr. Cathcart as modified by myself 
{Annals of Surgery, February, 1896). This 
kept the cavity entirely free from pus. 
At the time of the operation the cavity 
held considerably more than a quart of pus. 
In two weeks there had been such contrac- 
tion that it held less than a pint. He was 
discharged on January 22, 1896. There was 
still a small fistulous opening, leading to a 
cavity holding about three ounces. By the 
end of February it only held two ounces, 
and the falling in of the flap was rapidly ad- 
vancing toward cure. 
The operation that I did in this case, and 
also in another {Annals of Surgery, June, 
1895), is not precisely that of Schede in its 
details, but practically is the same, and I 
have therefore called it by his name, though 
I employed it in my first case without know- 
ing that Schede had ever done it. His 
original paper will be found in the Verhandl. 
d. Cong. Innere Med., 1890, p. 41. Schede's 
operation is not as well known in this 
country as it ought to be. Ferguson {four- 
nal of the American Medical Association, 
Jan. 9, 1897) in reporting a case stated 
that in looking through American medical 
literature he had not been able to find any 
other case whatever, overlooking the first 
case of my own to which I have just referred. 
Estlander's operation (thoracoplasty) is very 
well known and finds a place in all the text- 
books. Schede's, which is a radical improve- 5 
ment of the same, receives bare mention in 
the recent systems of Park and Dennis, and 
is not even referred to in Mr. Treves' Sys- 
tem of Surgery or in his Operative Surgery. 
The American Text-book of Surgery de- 
scribes the operation quite fully. 
Fig. 2. 
The operation of Schede is especially ap- 
plicable to very old cases in which the pleura, 
as in the present case, reaches the thickness 
of an inch or an inch and a quarter. It is 
very evident that mere removal of the ribs, 
leaving such a thickened pleura, will do no 
good, since the pleura is so stout and firm 
that it preserves the arch of the chest wall 
and therefore the cavity persists. Accord- 
ingly, the principle of Schede's operation is 
to make a flap of the soft parts down to th,e 
ribs, and then remove ribs, intercostal mus- 
cles and thickened pleura entirely. The flap, 6 
which has been raised, is then replaced so 
that the skin and subcutaneous tissues lie 
directly on the inner side of the old thick- 
ened pleura, which should be thoroughly 
curetted before the flap is replaced. 
The incision begins (see Fig. 2) at the 
level of the axilla in front, extends below 
to the lower border of the pleura, and then 
curves upward posteriorly to the level of the 
second rib between the scapula and spine. 
The entire soft parts (including the scapula) 
Fig. 3. 
down to the ribs are then raised. All of the 
ribs from the second or third downwards and 
from the costal cartilages to the tubercles are 
removed. The thickened pleura is then, in 
the entire extent of the wound, split, and 7 
with the intercostal muscles are removed 
with a strong shears. In both of my own 
cases I have not first resected the ribs and 
then the pleura as was done by Schede, 
but I have divided the entire chest wall 
under the soft parts by a strong pair of 
bone pliers. If the intercostal arteries bleed 
they are, of course, ligated. In my own 
cases I did not have to ligate any of them. 
Apparently the crushing of the forceps jaws 
prevented the hemorrhage. After thorough 
curetting of the visceral layer of the pleura, 
the flap is then laid upon the lung and pleura 
where it usually heals per primam, with an 
immediate subsidence of the fever. In both 
of my own cases I have found it necessary to 
drain for a considerable period. The best 
method by far of accomplishing this object 
is by the Cathcart drainage. 
The same free motion of the arm which 
I obtained in my first case is equally evident 
in the present case (Fig. 3). The left lung 
has expanded more than I had believed pos- 
sible-to the third rib. There is a marked 
left dorsal lateral curve, so that the vertebral 
ends of the ribs reach the posterior axillary 
line. The whole left chest wall is unexpect- 
edly firm and protects well the heart, the 
pulsation of which is very evident and is still 
displaced to the right.