OUR SURGICAL HERITAGE
Modern History of Surgical Management of Lung
Abscess: From Harold Neuhof to Current Concepts
Michael Schweigert, MD, Attila Dubecz, MD, Rudolf J. Stadlhuber, MD, and
Hubert J. Stein, MD, FACS
Department of General and Thoracic Surgery, Klinikum Nuremberg Nord, Nuremberg, Germany
Harold Neuhof was one of the pioneers of thoracic
surgery in the early decades of the last century. Inspired
by his preceptor Howard Lilienthal he proposed an
entirely new concept for surgery on acute lung abscess.
The aim of his one-stage procedure was adequate drain-
age of the abscess cavity. His approach proved to be the
first major breakthrough in the treatment of acute lung
M odern history of surgery for primary lung abscess
begins with the dawn of thoracic surgery in the
first decades of the 20th century. Although lung abscess
as a disease entity was known since the days of Hippo-
crates, successful surgical therapy had yet to be invented.
Harold Neuhof, when he was surgeon to the Mount Sinai
Hospital in New York during the 1920s and 1930s, was the
first thoracic surgeon to develop a valid and reliable
therapeutic concept for surgery of acute pulmonary ab-
scess. Based on the preliminary work of his surgical
preceptor Howard Lilienthal he proposed an entirely
new one-stage open drainage operation for lung abscess
[1]. Although contemporary series regarding lung ab-
scess reported mortality up to 75% [2], Neuhof’s series of
162 cases managed by his one-stage open drainage op-
eration showed mortality of only 2.47%. His findings
were soon generally accepted and displayed reproduc-
ible, good results in series from other thoracic surgical
services [3]. With the advent of antibiotics in the late
1940s, the spectrum of disease shifted toward chronic
pulmonary abscess. Acute lung abscess, the original
indication for Neuhof’s surgical procedure, became a
domain of medical therapy. Neuhof himself realized that
chronic and particularly multilocular lung abscess were
poor candidates for open drainage procedures [4].
Henceforth pulmonary resection for mainly chronic lung
abscess was considered the treatment of choice. Protag-
onists of this new era were, among others, Robert R.
Shaw, Richard T. Myers, and David H. Waterman [5–7].
However, the basic principles of Neuhof’s work are still
present in modern-day management of putrid lung ab-
scess, and his concept of open drainage was occasionally
advocated throughout the last decades. This historical
Address correspondence to Dr Schweigert, Klinik fuer Allgemein-, Visz-
eral- und Thoraxchirurgie, Klinikum Nuernberg Nord, Prof-Ernst-
Nathan-Strasse 1, 90419 Nuremberg, Germany; e-mail: michael.
schweigert@klinikum-nuernberg.de.
© 2011 by The Society of Thoracic Surgeons
Published by Elsevier Inc
abscess. Therapy of pulmonary abscess was again radi-
cally changed by the advent of antibiotics in the late
1940s. However, the basic principles of Neuhof’s concept
still influence modern-day management of putrid lung
abscess.
(Ann Thorac Surg 2011;92:2293–7)
© 2011 by The Society of Thoracic Surgeons
overview reports on the pioneering work of Harold
Neuhof and its consequences up to present times.
Early Years: Studies by Harold Neuhof
In the first two decades of the 20th century, the outcome
of patients with putrid lung abscess was nearly always
fatal. Acute lung abscess was a crushing and life-
threatening disease entity. Mortality reached 75% in a
series from the Massachusetts General Hospital covering
the years 1909 to 1923; 169 of 227 patients admitted to the
hospital for acute lung abscess died in spite of conserva-
tive treatment efforts [2]. Nonoperative management in
that era mainly consisted of unspecific drug therapy and
recommendation of fresh air and rest, as well as postural
drainage and occasionally bronchoscopic treatment.
However, those measures often failed to provide cure,
and thus lung abscess remained an unsolved medical
problem with substantial morbidity and mortality.
Doctor Harold Neuhof graduated from the College of
Physicians and Surgeons of Columbia University in 1905.
In the same year he began his internship at the Mount
Sinai Hospital in New York. At Mount Sinai, Dr Howard
Lilienthal, one of the most renowned surgeons of that
time, became his preceptor [8]. During a time when MISCELLANEOUS
thoracic surgery was trying to find its feet, Lilienthal
applied himself to this new field of surgical practice [9].
In the early decades of the last century, thoracic surgery
was mainly concerned about procedures for tuberculosis
and all kind of suppurative lung disease. Lung cancer
was not yet a topic of interest. Instrumentaria, operative
technique, and anesthesia were just emerging. One of the
pioneers in that field was Lilienthal. In 1910 he reported
the “first case of thoracotomy in a human being under
anaesthesia by intratracheal insufflation” in a 55-year-old
man with a pulmonary abscess [10]. This technical ad-
vance considerably improved the possibilities of lung
surgery, and in February 1914 Lilienthal performed his
first successful lobectomy [11]. His patient was a small
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 2294 OUR SURGICAL HERITAGE SCHWEIGERT ET AL
MODERN SURGICAL MANAGEMENT OF LUNG ABSCESS
boy who had accidentally aspirated a nut and subse-
quently experienced an abscess of the right lower lobe.
After an initial ineffective drainage procedure, the boy=s
condition deteriorated and so finally lobectomy was
performed [11]. Lilienthal had also much interest in the
treatment of pleural empyema, and in 1917 he published
a series comprising 100 consecutive patients who had
undergone surgical therapy of pleural empyema at the
Mount Sinai Hospital [12].
During his internship and residency Neuhof became
familiar with the work of Lilienthal, who acted as his
preceptor and clinical teacher [8]. In World War I,
Neuhof served with the Presbyterian Hospital Unit (Base
Hospital No. 2) in France. Here he gained further expe-
rience in dealing with chest wounds and empyema as a
result of infected thoracic injury. After the war he became
Associate Surgeon at Mount Sinai, and after the retire-
ment of Lilienthal, he took charge of the thoracic surgery
department [8].
Based on the extensive preliminary work of his prede-
cessor, Neuhof became especially interested in the sur-
gical management of acute putrid abscess of the lung. His
research included the etiology, bacteriology, and pathol-
ogy of pulmonary abscess [13]. He recognized that “an
acute putrid abscess usually is solitary, of substantial
proportions, superficially situated within the lung and
overlaid by well-developed visceroparietal agglutinating
adhesions” [1]. In the early 1920s no commonly accepted
therapy for lung abscess existed. It was considered to be
an almost inevitably fatal illness. Neuhof proposed the
entirely new concept of a one-stage open drainage pro-
cedure, which had tremendous effect in decreasing mor-
bidity and mortality of acute lunge abscess and was
therefore generally adopted by his contemporaries in
very short time.
Neuhof realized the importance of “precise roentgen-
ologic localization” for accomplishing his one-stage op-
eration [1]. Together with his Mount Sinai colleague Dr
Rabin he developed a method of spot localization using
the radiologic possibilities of that time [14]. After diverse
radiographs, the “assumed point of contact of the pul-
monary abscess with the thoracic parietes is determi-
ned. . . . The intercostal musculature at this point is
injected with a small amount of a mixture of iodized oil
and methylene blue. A new set of roentgenograms is
MISCELLANEOUS
taken. There is then revealed the exact relationship of the
spot to the abscess” [1]. This simple procedure enabled
Neuhof not only to localize the abscess very precisely but
also to approach it directly by a limited incision without
touching the free pleural cavity.
Neuhof performed his operation mainly under local
anesthesia. Subperiosteally, “a two- or three inch seg-
ment of one rib” was removed and the underlying lung
was carefully exposed [1]. “The adhesions are delicately
traversed over a small area down to adherent lung” [1].
He was especially concerned about preserving enough
adhesions to keep the free pleural cavity sealed to avoid
pleural empyema. The abscess was then aspirated with a
short aspirating needle [1]. After the correct position of
the needle was ascertained, the abscess was unroofed
Ann Thorac Surg
2011;92:2293–7
with special equipment developed by Neuhof and his
coworker Touroff [15]. “The aspirating needle being held
in place, we follow with a cutting grooved director and
cutting scissors, urging the patient to avoid coughing at
this stage. . . . Under full visualization the shell of lung
over the abscess is generously excised within the limits of
pleural adhesions” [1]. All suppuration and clotted blood
was then removed by suction, and the operation termi-
nated by gauze tamponade of the cavity. “Tamponade is
a correct term for the gauze pack of the cavity for the
purpose is to avoid collapse and consequent shutting off
of any part of the abscess” [1]. The chest wound itself
remained unclosed.
Postoperatively the prompt termination of expectora-
tion of foul pus was considered to confirm successful
treatment, whereas persistence of the former indicated in
all probability an inadequate procedure [1]. Furthermore,
Neuhof was considerably concerned about wound clo-
sure. “We have learned that after an adequate operation
the premature closure of an abscess cavity may, and often
will, lead to recurrence of the manifestation of pulmo-
nary abscess” [1]. Therefore, the wound was usually kept
open until the patient had clinically and radiographically
recovered.
During the procedure Neuhof regularly encountered
bronchial fistulas within the abscess cavity. “The disclo-
sure of one or more bronchial fistulae is clear evidence
that the main chamber of the abscess has been opened. A
fistula often can be demonstrated by having the patient
cough or strain” [1]. Thus, the discovery of bronchial
fistulas indicated a sufficient procedure with unroofing of
the main part of the abscess cavity. Neuhof kept the
fistula together with the wound open until definite heal-
ing of the abscess was achieved. He was particularly
concerned about premature closure of either wound or
fistula. “Therefore, the wound is kept open and the
bronchial fistula maintained until the patient is free from
cough and expectoration. . . . Failure to adhere to these
standards has led to recurrence of the pulmonary ab-
scess” [1]. Neuhof did not report on any problems related
to persisting peripheral bronchial fistula. After cure had
been accomplished the fistulas healed naturally. “We
stressed the fact that in case of acute abscess practically
all bronchial fistulae closed spontaneously, and that one
of the chief problems in postoperative management was
that of keeping the fistula open for a sufficiently long
period” [4].
With strict adherence to this procedure Neuhof
achieved excellent results. In 1943 he reported a series of
162 patients who had been managed by his one stage
open drainage operation at the Mount Sinai Hospital
since 1925 [1]. He encountered only 4 death which means
an overall mortality of 2,47%. The late results of his series
were also encouraging. Some sufferers who had died
years later of reasons unrelated to the former lung
abscess were autopsied. Upon postmortem examination
complete healing of the pulmonary abscess was con-
firmed. Hence prompt recovery following the procedure
and reassuring long-term results rapidly led to a wide-
spread acceptance of Neuhofs one stage open drainage
Ann Thorac Surg
2011;92:2293–7
operation. In 1943 13 of 15 patients admitted to the
Massachusetts General Hospital in Boston due to lung
abscess received surgery in the form of Neuhofs one
stage open drainage procedure with encouraging results
[16]. Neuhof himself stated, “Putrid lung abscess is po-
tentially a surgical lesion from the outset. There is no
proved method of definitely influencing the course other
than by operation” [1].
Middle Years: Other Surgical Studies
Inspired by the reports published by Neuhof throughout
the 1930s [13, 17], Robert R. Shaw retrospectively ana-
lyzed the results of medical or delayed two-stage surgical
treatment of lung abscess at the University Hospital at
Ann Arbor, Michigan, between the years 1926 and 1937
[3]. He identified 227 cases. Nonsurgical treatment led to
recovery in just 21.6%, whereas mortality was 30%. After
failed initial medical therapy, altogether 138 patients
underwent a two-stage operation with delayed drainage
of the abscess cavity. This staged procedure had substan-
tial mortality of 40.6% [3]. Postponement of surgery
because of prolonged conservative therapy resulted in
poor preoperative condition and an already seriously
deteriorated functional status. General mortality for all
227 cases therefore amounted to 35.7% [3].
Disappointed in the discouraging outcome of the treat-
ment thus far used and based on the results of Neuhof,
Shaw also started to perform the one-stage open drain-
age procedure rather than a two-stage approach. In case
of acute solitary lung abscess he was henceforth able to
reduce mortality to 5%; 80% of the sufferers recovered
well, and the remaining were at least improved [3]. So the
procedure suggested by Neuhof displayed reliable, re-
producible, good results in other surgical services, too.
Medical Treatment of Lung Abscess
Around 1946, management of pulmonary abscess under-
went another radical change owing to the advent of
antibiotics [16]. Although sulfonamides had shown dis-
appointing results, antibiotics and notably penicillin rev-
olutionized the therapy of lung abscess. Since 1946,
treatment of acute putrid lung abscess with penicillin
showed good results, and henceforth patients received
antibiotics rather than surgical procedures [18, 19]. A
series of 115 cases of acute lung abscess was collected at
the Massachusetts General Hospital between the years
1943 and 1956 [16]. Patients were either treated medically
with antibiotics or surgically in case of failing medical
therapy. Although mortality of lung abscess in the same
hospital had been 75% in the period between 1909 and
1923 and were still 33.9% between 1933 and 1937, it was
now reduced to 8.7% [2, 16]. Mortality decreased further
to 6.9% from 1947 to 1956, when antibiotics were already
ubiquitously available [16]. Twenty-one of 51 patients
finally required surgery, whereas 30 patients were
successfully managed nonoperatively. An open drain-
age procedure as proposed by Neuhof was performed
in only 5 patients. The last such operation was done in
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MODERN SURGICAL MANAGEMENT OF LUNG ABSCESS
1950, and from that time on, pulmonary resection was
preferred [16].
The advent of penicillin not only overthrew the surgi-
cal treatment of lung abscess, it brought about a substan-
tial decline in the incidence of lung abscess, too. In 1944,
10.8 cases per 10,000 admissions to the Massachusetts
General Hospital were noted, whereas lung abscess was
only responsible for 0.6 cases per 10,000 hospital admis-
sions in 1951 [16]. The reduced incidence of lung abscess
was not solely caused by widespread use of penicillin but
also induced by better operative management of head
and neck surgery, and particularly by the improved
prevention of aspiration after either tonsillectomy or
tooth extraction [16]. Therefore, putrid lung abscess be-
came a rare disease and was henceforth only infre-
quently encountered in medical or surgical departments.
Multilocular Chronic Lung Abscess
Acute lung abscess had become a domain of medical
treatment. Nevertheless, antibiotic therapy also consid-
erably shifted the spectrum of disease. Throughout the
1920s and 1930s acute putrid lung abscess caused by
pneumonia or aspiration had dominated among patients
admitted to surgical services. However, with the wide use
of antibiotics and generally accepted initial medical treat-
ment, mainly cases of multilocular, chronic lung abscess
were now referred to the thoracic surgeon. Although
nonsurgical therapy had failed in those cases, they were
also not perfectly suitable for the open drainage proce-
dure of Neuhof [3, 4].
Neuhof himself defined acute abscess as a commonly
solitary, superficially situated abscess of less than 6
weeks’ duration [1]. He defined abscess with a duration
from 6 to less than 12 weeks as subacute, and all ab-
scesses of more than 12 weeks’ duration were termed
chronic [1, 4]. Neuhof recognized that chronic lung ab-
scess was often multilocular, showing diffuse lesions.
Results of open drainage procedures for this diffuse type
of chronic lung abscess were discouraging, with signifi-
cant mortality. In 1941 he reported a series of open
drainage operations on subacute and chronic lung ab-
scess [4]. Patients with a localized solitary abscess did
well regardless of the age of the lesion. However, 25 of 41
patients operated on for multilocular subacute or chronic MISCELLANEOUS
abscess died, and only 5 patients were cured. Neuhof
himself concluded in 1941 “that drainage operations
should not be employed in cases of abscess of the lung of
the diffuse type. Whether more radical surgical proce-
dures such as lobectomy or pneumectomy meet the
requirement of good results with low mortality remains
to be seen” [4].
In 1942 Shaw stated that “lobectomy and total
pneumectomy may at times be procedures of choice in
dealing with multiple chronic abscesses” [3]. Several
series of the late 1940s and 1950s confirmed this state-
ment [5–7]. Pulmonary resection either as lobectomy or
even as pneumectomy became established as the treat-
ment of choice in patients with chronic lung abscess in
 2296 OUR SURGICAL HERITAGE SCHWEIGERT ET AL
MODERN SURGICAL MANAGEMENT OF LUNG ABSCESS
whom initial medical treatment had failed to provide a
cure.
Later Years: Rediscovery of Neuhof’s Procedure
Henceforward the debate about adequate treatment of
lung abscess calmed down, and only a few significant
reports were published until the 1980s. In 1982 Hagan
and Hardy from the University of Mississippi reported a
large series of 184 patients with lung abscess who had
been treated at their institution between the years 1960
and 1982 [20]. Only 11% required surgery, whereas 89%
of the cases were managed nonoperatively. Altogether 16
lobectomies and three pneumectomies were performed.
During the whole study period, mortality remained
equal, with 22% in the 1960s, 25% in the 1970s, and 28%
from 1980 to 1982 [20].
The report of Hagan and Hardy showed, on the one
hand, that the great majority of cases could be managed
by nonoperative means; on the other hand, it also high-
lighted constant mortality at a substantial level. The high
mortality of pulmonary abscess was attributed to increas-
ing prevalence of immunosuppressive therapy, including
chemotherapy in case of malignant disease. Neverthe-
less, the study’s findings also clearly confirmed that lung
abscess was a rare and infrequent disease. Mainly pa-
tients with predisposing factors such as chronic alcohol-
ism, diabetes, immunosuppression, seizure disorders,
and proximal foregut carcinomas sustained putrid pul-
monary abscess [20]. Because of the emergence of ac-
quired immunodeficiency syndrome, the technique of
Neuhof was once more remembered [21]. It was consid-
ered to be an alternative treatment in patients too sick to
undergo pulmonary resection [21].
Postma and Le Roux from the University of Natal and
Wentworth, Durban, published one of the largest series
so far on open drainage of lung abscess in the South
African Journal of Surgery in 1986 [22]. During the 1970s,
268 patients with lung abscess had been admitted to their
institution. These patients were predominantly managed
conservatively, but a total of 78 patients finally required
surgery (29.1%). Pulmonary resection in some form was
performed, but mortality amounted to 15.4% [22]. Dissat-
isfied with this result, Postma and Le Roux decided to
MISCELLANEOUS
change the operative procedure of patients requiring
surgery for lung abscess. From 1978 on, they managed
lung abscess by open drainage rather than by resection.
Between the years 1978 and 1984, 417 cases of lung
abscess were seen, and 115 patients finally underwent
surgery. Severe hemoptysis, uncertain diagnosis, or pul-
monary gangrene necessitated pulmonary resection in 47
patients, whereas 68 cases were managed by open drain-
age. Mortality and morbidity declined sharply to 0.9%,
and 56 of the patients with initial open drainage recov-
ered without need of later pulmonary resection. There-
fore Postma and Le Roux concluded that “open drainage
is a simple, successful and relatively complication-free
treatment for necrotizing pneumonia refractory to med-
ical treatment” [22].
Ann Thorac Surg
2011;92:2293–7
A group from Israel suggested two-stage treatment of
pulmonary gangrene in 1997 [23]. They reported on 3
patients with lung necrosis caused by multiple lung
abscesses and pleural empyema. The two-stage treat-
ment comprised immediate fenestration with subsequent
daily irrigation of the pleural cavity and pneumectomy 1
week later with simultaneous closure of the pleural
window. All 3 patients recovered well, and the authors
concluded that preliminary fenestration of the chest wall
would enable a safe and curative resection of gangrenous
lung in a clean field and in a clinically improved patient
[23]. However, this procedure had the severe disadvan-
tage of leaving the gangrenous lung as a source of septic
disease within the patient for another week and was
therefore not widely adopted.
During the last 5 years, 20 consecutive patients re-
ceived surgical treatment for pulmonary abscess at our
own institution, a German tertiary referral hospital serv-
ing a population of approximately half a million people.
Initial medical therapy had failed in all cases. Preopera-
tively 65% of the patients already suffered from pleural
empyema, 25% had a persistent air leak, severe sepsis
was present in 40%, and 20% of the patients were there
because of respiratory failure already being preopera-
tively ventilated. Gangrene of a whole lung was encoun-
tered in 4 patients, whereas abscess or multiple abscesses
within one lobe were seen in the remaining 16 patients.
Limited procedures were feasible in 3 patients, whereas
13 patients required lobectomy and 4 patients even
underwent a pneumonectomy. Results were gratifying in
17 patients, although 3 patients died. Mortality amounted
to 15%.
The severity of disease displayed in our collective is
reflected in other recent reports, too [23, 24]. Life-
threatening, advanced septic illness and often even septic
shock with multiorgan failure is already present when
these patients are referred to the thoracic surgeon. The
source of sepsis is the gangrenous lung, and recovery will
in all probability only be enabled by removing this focus.
Nevertheless, there are still certain patients who can
successfully be managed by surgical drainage proce-
dures. Two of our 20 patients received an unroofing and
debridement of the abscess cavity as described by
Neuhof. No pulmonary resection was necessary, and
both patients recovered well. However, we prefer inser-
tion of chest tubes with underwater seal to open
drainage.
Summary
Until the 1920s acute lung abscess was a devastating
condition associated with mortality up to 75% [2]. Harold
Neuhof, one of the pioneers of thoracic surgery, accom-
plished the creation of an entirely new surgical concept
for treatment of pulmonary abscess [1]. His studies were
based on both the preliminary work of his preceptor
Howard Lilienthal and careful research on the etiology,
bacteriology, radiographic imaging, and clinical course of
putrid lung abscess. Because of Neuhof’s one-stage open
Ann Thorac Surg
2011;92:2293–7
drainage procedure, mortality and morbidity were tre-
mendously diminished [1].
With the advent of antibiotics at the end of the 1940s,
acute lung abscess became a domain of medical therapy,
and henceforth surgery was limited to chronic disease
after failed medical treatment [16]. However, these cases
were mostly not suitable for open drainage, and therefore
pulmonary resection was established as the procedure of
choice [5–7].
Increasing incidence of immunosuppressive therapy
and the emergence of acquired immunodeficiency syn-
drome in the 1980s caused a return at least to the
principles of Neuhof’s open drainage operation for a
selected subgroup of patients whose performance status
is too poor to undergo pulmonary resection [21]. Inde-
pendently a large series from South Africa confirmed that
the open drainage procedure as proposed by Neuhof still
provides reliably good results in the treatment of lung
abscess [22].
Recent reports as well as our own experience indicate
that patients referred to the thoracic surgeon often suffer
from severe sepsis owing to advanced necrotizing infec-
tion refractory to medical treatment [23, 24]. These pa-
tients require pulmonary resection for effective control of
septic disease. However, there are patients with localized
abscess who can be sufficiently managed by unroofing
and drainage of the abscess cavity. Either way, adequate
control of the septic focus remains the primary goal of
surgical therapy. Thus the basic rule of Neuhof’s opera-
tion still has considerable impact on current therapeuti-
cal concepts.
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