CLASSICS IN THORACIC SURGERY
Gotthard Bulau and Closed Water-Seal Drainage
for Empyema, 1875-1891
John A. Meyer, MD
Department of Surgery, State University of New York Health Science Center, Syracuse, New York
Optimal treatment of pleural empyema remains contro-
versial to the present day. In the preantibiotic era,
surgical thinking favored early and aggressive drainage
of closed-space infections, but the dynamics of the pleu-
ral space were poorly understood and open pneumotho-
rax generally was considered the necessary price of
surgical drainage. Against bitter opposition, revision of
the dogma of early open drainage was achieved in 1918
by Evarts Graham and his associates on the US Army's
Empyema Commission. Unacceptable mortality rates for
early drainage were brought under control through a
treatment program of repeated tapping, with surgical
T he first therapeutic dilemma encountered by thoracic
surgery in its infancy, suggested Dr Edward D.
Churchill in a scholarly discussion, was the management
of penetrating wounds of the chest [l].Should the wound
be closed to stop sucking and blowing of air into and out
of the pleural space or left open to allow for drainage of
blood, exudate, and the almost inevitable suppuration?
"Close the wound," Ambroise Pare had concluded in
1575, on condition that blood was not retained within the
chest, "for fear that cold air will penetrate in to the heart,
and the vital spirits depart and vanish." In one guise or
another, the dilemma of the chest wound has persisted
almost to the present day.
Treatment of pleural empyema posed another intracta-
ble and recurring problem, one that reached crisis propor-
tions during the world influenza pandemic of 1918 to
1919. The epidemic killed more people than did all the
shells, trenches, machine guns, and poison gas of World
War I. In the United States, draftees crowded into the
Army camps were especially vulnerable to its complica-
tions. Churchill again describes the period vividly:
The streptococcal pneumonia and empyema which accom-
panied the influenza epidemic was a new disease to a gener-
ation of doctors. They had no precedents which defined
it. . . . Early evacuation of streptococcal pus was taught as a
dogma of the surgery of the period. . . . Cyanotic patients,
with pulmonary reserves crippled by massive and oftentimes
bilateral bronchopneumonia, were being hurried to an oper-
ating room as soon as thoracentesis yielded fluid containing
chains of streptococci. The operation was rib resection with
open tube drainage. Death occurred quite frequently about
half an hour after the operation [l].
Quotations from Bulau's paper are in translation by Dr Meyer.
Address reprint requests to Dr Meyer, 750 E Adams St, Syracuse,
NY 13210.
0 1989 by The Society of Thoracic Surgeons
drainage only after loculation had occurred. Paradoxi-
cally, closed water-seal drainage for empyema had been
used by a German internist, Gotthard Bulau, as early as
1875. His technique was published in 1891, 27 years
before the report of the Empyema Commission. As a
closed system, it would have been suited to empyema
drainage in either the early diffuse or the loculated
stages. Thoracotomy was not possible at the time, and
Bulau probably could not foresee the future importance
of his method to surgery.
(Ann Thoruc Surg 1989;48:597-9)
A survey by the Surgeon General of the Army in
February 1918 found mortality rates for empyema drain-
age in the base hospitals to be averaging 30% [2]. He
appointed a commission to study the problem, headed by
Major Evarts A. Graham; the Commission's conclusion
and recommendations are a familiar landmark:
In the light of all these observations it would seem defi-
nitely established that an operation for empyema performed
too early in the course of the disease is accompanied by such
very grave danger that in our opinion the risk of harm by the
operation outweighs any advantages which it may have. . . .
The only advantage to be gained from an early operation is
drainage which theoretically accomplishes the removal of
both toxic material and living organisms and in addition
relieves mechanical embarrassment to respiration caused by
the presence of a large amount of fluid. Practically, however,
the mechanical embarrassment to respiration is almost sure to
be aggravated instead of improved because of the creation of
an open pneumothorax; and moreover, the fluid can be
withdrawn by aspiration as often as it accumulates in any
considerable amount, a procedure which, of course, also
removes some of the toxic material and living organisms. The
apparently theoretically ideal method of continuous drainage under
negative pressure involves the necessity of a special attendant to
prevent a delirious patient from interfering with the apparatus and
thus running the risk of creating an open pneumothorax . . . [Italics
added].
Practically it may be stated that, in general, the safest time
to operate is when the exudate has become frank pus instead
of being merely serofibrinous, for the following reasons: 1)
There is less danger of creating an open pneumothorax
because, in our experience, there is likely to be a circum-
scribed abscess shut off by adhesions from any communica-
tion with the free pleural cavity so that during the operation
the pleural cavity, properly speaking, is not entered . . . [Z].
Immediately after adoption of these changes, mortality
of empyema drainage in Army hospitals decreased to
4.3% [2]. Closed catheter drainage obviously was known
OOO3-4975/89/$3.50
598 CLASSICS MEYER
CLOSED WATER-SEAL DRAINAGE FOR EMPYEMA
Fig I . Gotthard Bulau (1836-1900) of Hamburg, Germany, origina-
tor of the method of closed water-seal drainage of the chest. (Reprinted
by permission of the publisher from Nissen R, Wilson RHL. Pages in
the history of chest surgery. Springfield, IL: Charles C Thomas,
1960.)
in the United States at the time, but was not entirely
accepted as a reliable method of treatment. Why not? The
reasons may be difficult to understand after this lapse of
time. Graham and Bell [Z] perceived the risk of the patient
accidentally pulling out the tube. Tube drainage may have
been regarded as a method developed in the enemy
country; Major Pierre Duval of the French Army medical
corps and Colonel Berkeley Moynihan of the British
publicly condemned German surgical methods (such as
differential pressure chambers) during lecture tours of the
US [l]. And finally, surgery in the US was barely arriving
at the point at which the open chest under anesthesia
could be considered even a possibility. Physiological
findings from the laboratory had not yet made much
impression on surgical practice. Suction drainage of the
pleural cavity after lobectomy would not be described for
more than a decade, in the report of Harold Brunn [3].
Closed water-seal drainage for empyema, however, dated
back at least to 1875.
A Prophetic Insight
Gotthard Biilau (Fig l), born in Hamburg in 1836, prac-
ticed internal medicine with an interest in pulmonary
disease. Thoracic empyema, usually postpneumonic, was
an unsolved problem. Surgical treatment in the acute
phase consisted of rib resection with open tube drainage;
in the chronic phase, the thick-walled indurated space
was often managed by excision of the overlying ribs and
chest wall, “saucerization” of the space, as it came to be
called. Surgeons for the most part considered postopera-
tive deaths to be the result of infection rather than a
superimposed respiratory handicap. Few accepted the
validity of laboratory studies showing the importance of
Ann Thorac Surg
1989;48:597-9
negative intrathoracic pressure. Biilau was familiar with
these concepts, however, and evolved a method of closed
drainage which he eventually published in 1891 [4].
In the proceedings of this year‘s medical congress in Vienna
on the management of empyema, only two methods came
under discussion: the radical operation involving resection of
the overlying ribs, and siphon-drainage. While advocates of
the first method were in the majority,*the last-named method
also had its strong supporters, and the results they presented
deserve comparison. Although the results obtained recently
after rib resections have been extraordinarily favorable, the
question remains whether in the majority of cases, one would
not wish to use a safer and less complicated method. There
can be no difference of opinion, that siphon drainage involves
a less severe operative injury. . . . 1 have always believed that the
principal advantage of siphon-drainage is that it lolvers the pressure
within the pleural space, thereby bringing about reexpansion of the
lung [Italics added].
Biilau described his technique of drainage in detail (p 37):
It is easier on the patient, if one first makes a small incision
through the skin with a Bistoury or lancet, over the site where
the trocar is to be inserted, long enough to allow the trocar to
pass through; the skin itself offers the principal resistance,
and if not incised will make the trocar puncture difficult and
painful. Immediately after removal of the trocar-point, the
catheter is passed through the cannula, the cannula is pulled
back over the catheter, and the skin is securely closed around
it. Then, it is convenient to clamp the catheter for a short time
and to secure it in place, before connecting it to the siphon
apparatus. I place a suture in the skin, tying it directly to a
safety pin placed in the catheter at the level of the skin; both
ends are secured, and the site is covered with gauze sponges
and collodion, or by strips of adhesive plaster extending from
front to back of the chest wall . . . After the catheter has been
secured, it is attached to the siphon-apparatus which has
previously been filled with antiseptic solution. The free,
weighted end of the rubber drainage tubing is immersed in a
bottle filled one-third full of the same solution, and the
occluding clamp is removed. Now the pus flows slowly out of
the chest cavity, and as a result the lung must expand by a
precisely equal volume.
A precautionary measure, to which little attention has been
paid, is to secure the drainage tubing to the edge of the
patient‘s bed or mattress, and indeed to allow a slack loop of
40 to 50 cm of the tubing to lie beside the patient in bed. By
doing this, one can prevent the weight of the tubing and
apparatus from pulling constantly on the catheter within the
chest, thereby causing pain and the risk of its slipping out;
also it allows the patient free movement in bed and the ability
to turn into a comfortable position . . . If the apparatus
functions well from the beginning, and the pus is completely
evacuated, we can expect the fever to fall immediately in
uncomplicated cases. If the fever recurs, suppuration in the
drainage tract is usually to blame, or else the catheter has
become plugged by some kind of obstruction.
Biilau reported several case histories, the earliest that of a
man treated in 1875 (p 41).
W., 35-year-old carpenter, admitted April 11, 1875. Illness
began with chills on April 6th. Pleuropneumonia left lower
lung. High fever, delirium. Beginning on the 17th, profound
‘[Present author‘s note] Biilau mentions Schede several times as having
been present and among the majority favoring resection of the overlying
chest wall.
Ann Thorac Surg
1989;48:597-9
sweats with intermittent fever. At the beginning of May,
dullness over the entire left chest, which had 3 cm greater
circumference than the right. Displacement of the heart.
Edema of the legs and the left chest wall. May 4: 2,250 cm3 of
pus withdrawn by tapping and siphon-drainage. May 1 7
daily drainage of about 100 cm’ of pus; catheter easily ob-
structed by blood clots. Injection of calcium solution. Patient’s
general appearance much better. Continued improvement;
discharged September 6 with the fistula closing.
Readmitted June 28,1876. Two months after discharge from
the hospital, exudate again had appeared from the drain
wound, with alternate coughing and purulent discharge.
Examination of the chest showed no significant differences
between the two lungs. Catheter was again placed into the
fistula and connected to siphon drainage. Thereafter, cough
ceased and purulent drainage was minimal. July 25: the
patient was discharged with drain in place, and returned
every 8 days for dressing. In November the drain was
removed, with subsequent complete healing. Over the inter-
vening years, I have observed him to maintain full health and
activity.
[Concluding, p 45) In view of the observation reported
here, of healing of an empyema fistula of 15 months’ duration
under siphon-drainage, with reexpansion of the lung, I be-
lieve that if faced with a similar case one would be entirely
wrong not to make a search of the literature for alternative
treatment, before proceeding to chest-wall resection.
Did Biilau foresee the importance of his method to the
future development of surgery? He speaks of the method
as siphon-drainage, implying that he considered it a
hydraulic mechanism for evacuation of fluid from the
chest. Did he understand also that closed water-seal
drainage could bring about reexpansion of the lung (as-
suming no air leaks from the lung) solely on the basis of
the patient’s own respiratory movements?
In this situation the drainage can function as a valve,
allowing escape of pus and the air which has entered during
CLASSICS MEYER 599
CLOSED WATER-SEAL DRAINAGE FOR EMPYEMA
the operation, while preventing renewed entry of air from
without . . . With each forcible expiration against a closed
glottis, the air in the opposite (healthy) lung is forced into the
partially collapsed one, inflating it and driving out a corre-
sponding amount of drainage through the cannula. With the
next inspiration the valve closes, the lungs are further ex-
panded, the expansion is maintained, and with the next
expiratory stroke expansion proceeds a step further [4].
Closed drainage: could it be used for procedures other
than empyema drainage? In 1891 when the article was
published, intentional thoracotomy was not possible in
any case. No method existed for maintenance of pulmo-
nary ventilation under anesthesia in the presence of open
pneumothorax. The chambers incorporating differential
pressures, Unterdruck and iiberdruck, were not to be
described until 13 years later, in 1904 [5, 61. Thoracotomy
had not yet been developed and Biilau was not a surgeon,
but his insight would be indispensable to the surgery of
the future.
References
1. Churchill ED. Wound surgery encounters a dilemma. J Thorac
Surg 1958;35:279-90.
2. Graham EA, Bell RD. Open pneumothorax: its relation to the
treatment of empyema. Am J Med Sci 1918;156:839-71.
3. Brunn H. Surgical principles underlying one-stage lobectomy.
Arch Surg 1929;18:490-6.
4. Bulau G. Fur die Heber-Drainage bei Behandlung des Empy-
ems. Z Klin Med 1891;18:3145.
5. Sauerbruch F. Zur Pathologie des offenen Pneumothorax und
die Grundlagen meines Verfahrens zu seiner Ausschaltung.
Mitt Grenzgeb Med Chir 1904;13:399-482.
6. Brauer L. Die Ausschaltung der Pneumothoraxfolgen mit
Hilfe des Ueberdruckverfahrens. Mitt Grenzgeb Med Chir
1904;13:483-500.