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A History of Thoracic Drainage: From Ancient Greeks to Wound Sucking Drummers to Digital Monitoring

Thursday, April 9, 2015

Tube thoracostomy is often the first step in the treatment of pneumothorax, hemothorax, hemopneumothorax, empyema, and pleural effusion. Although tube thoracostomy was not accepted as the standard of care for pneumothorax and hemothorax until the late 1950s (1), the idea of draining substances from the thoracic cavity has been documented for thousands of years (2, 3). For cardiothoracic surgeons today this basic skill is taken for granted and considered the simplest of the procedures now performed. There is little thought given to, or the awareness of, the rich history and gradual progression of this skill over the course of centuries that has brought us to our current understanding in the management of the chest tube. A review of this evolution provides us with a deeper appreciation of our specialty, and a new respect for the surgeons who have brought us this far.

The oldest known reference to thoracic drainage dates back to the fifth century B.C.E. Hippocrates (c. 460-370 B.C) (3) was a pioneer of a rational view of disease, in which the four humors of the body – blood, phlegm, black bile, and yellow bile – must be in balance to preserve health (4). In the Hippocratic texts “empyemas” could occur in any part of the body and were not distinguished from abscesses, although the “empyemas” located in the thorax were described most often. Conservative treatment with medications composed of plant materials and physiotherapy exercises was attempted first. If the patient did not improve, open evacuation of the empyema was undertaken (4):

First, cut the skin between the ribs with a bellied scalpel; then wrap a lancet with a piece of cloth, leaving the point of the blade exposed a length equal to the nail of your thumb, and insert it. When you have removed as much pus as you think appropriate, plug the wound with a tent of raw linen, and tie it with a cord; draw off pus once a day; on the tenth day, draw all of the pus, and plug the wound with linen. Then make an infusion of warm wine and oil with a tube, in order that the lung, accustomed to being soaked in pus, will not be suddenly dried out. When the pus is thin like water, sticky when touched with a finger, and small in amount, insert a hollow tin drainage tube. When the cavity is completely dried out, cut off the tube little by little, and let the ulcer unite before you remove the tube. (5)

Despite the fact that the incision would have to be deeper than the length of a thumbnail to remove pus comprising an empyema, this is the most common translation. Hippocrates left the drain in place for up to two weeks and was able to successfully treat inflammation with this procedure. Galen (c. 129-200 C.E.) describes a similar procedure for abdominal paracentesis, but does not comment on thoracic injuries (3).

The next recorded account of pus evacuation to facilitate healing of a chest wound is documented by Mitchell in Medicine in the Crusades. As described by Albert of Aachen and recounted by Guibert of Nogent, Baldwin I of Jerusalem (c. 1058-1118) was struck by a lance, and the treatment of draining pus from the wound was based on the experimental treatment of a bear with a similar injury. There are no other recorded descriptions of similar procedures from this era, implying they were not widely known or practiced at the time (6).

The first clear mention of a tube thoracostomy procedure may occur in Wolfram von Eschenbach’s Parzival, written between 1210 and 1220. He describes a knight named Gawan’s comments and action upon encountering a fallen knight named Uriens, who has sustained a chest wound in a joust (3):

There lay a man pierced through,
with his blood rushing inward…
“I could keep this knight from dying
and I feel sure I could save him
if I had a reed,
You would soon see him and hear
him in health, because
he is not mortally wounded.
The blood is only pressing on his heart.”
He grasped a branch of the linden tree,
slipped the bark off like a tube –
he was no fool in the matter of wounds –
and inserted it into the body through the wound.
Then he bade the woman suck on it
until blood flowed toward her.
The hero’s strength revived so that he could speak and talk again.” (7)

It is possible to conclude that although Gawan describes the life-threatening injury as “blood pressing on the heart," which could be interpreted as pericardial tamponade, the description of the mechanism of injury suggests Uriens sustained rib fractures which caused a tension hemopneumothorax (3). It is unclear if the use of chest tube thoracostomy for the treatment of tension pneumothorax as described by Wolfram, was a common battlefield or hospital procedure at the time. Surgery was a lucrative profession and surgeons often kept procedures secret for their own financial gain. Therefore, it is possible Wolfram, in this fictional work, documents a technique that was well known at the time but not described in medical texts (3).

In 1395, Guy de Chauliac, the leading physician-surgeon of medieval France, completed his Chirurgia Magna, the major surgical reference for the next century. In the second Doctrine, he comments with surprise on the lack of ancient writings concerning thoracic wounds, and reviews the disagreements between his contemporaries on the treatment of these wounds. Roger (Frugardi) of Salerno, Roland of Parma, William of Bologna, and Lanfranc of Paris believed in open treatment of penetrating thoracic wounds using tents and drains to allow blood and decaying organic materials to escape. Theodoric and Henri de Mondeville disagreed and advocated for the immediate closure of wounds to prevent the entry of cold air and loss of heat (8).

The debate regarding closed versus open treatment of thoracic wounds would persist for centuries. For the treatment of penetrating thoracic trauma, de Chauliac recommended: the use of a tent, daily instillation of warm wine or a honey and river water mixture, and patient rotation. The irrigating fluid was collected and measured for four or five days, or until the fluid collected decreased in volume and remained clear. Irrigation was then halted, the tent was left in place, and the wound was dressed with cotton to absorb residual drainage. Smaller tents and cotton dressings were used until the patient was healed (8). If this method did not result in the patient’s improved health, it was attributed to materials retained “upon the diaphragm.” This was treated with an inferior oblique incision along the ribs towards the spine, originally proposed by William of Salicet, followed by serial tenting and irrigation as described above. This was done without anesthesia (8).

Giovanni da Vigo, a well-known Italian surgeon and physician of Pope Julius II, was one of the first surgeons to discuss firearm wounds, including those to the chest, in Practica Copiosa of 1514. However, in the 1586 edition of Practica Copiosa in Arte Chirurgia, only nine pages are devoted to thoracic wounds (8, 9). As Guy de Chauliac did, Vigo acknowledges the disagreement over open versus closed treatment of penetrating thoracic injuries:

There bee manie that commaud to shut incontinentlie the penetraunt wounde, …saying, That if the sayde wound bee not shut, the aire will enter in unto the heart, and moreover, that the vital spirits wil issue out by the wound, which thing might hurt the patient…Againe, many be of a contrarie opinion, and command to keepe the wound open. And if the wound be not large, they saie it must be enlarged that the bloud may issue out, affirming that if the bloud which is in the inner part issue [not] out by the orifice of the wound, it may ingender many evil accidents and corrupt the inner members. (8)

Vigo advocated for open treatment, but conceded the possibility of wound closure on the first day if no blood was retained. (8)

Later in the sixteenth century, French military surgeon Ambroise Paré described the diagnosis of a penetrating chest wound (8), and in 1575 quoted Vigo as he attempted to establish guidelines to determine open or closed treatment for penetrating thoracic wounds. According to Paré, a wound should be left open if there was blood in the chest because if closed, the blood would “decompose and putrefy,” and would “provoke fever, fistula, and other complications.” In these cases, he kept the wound open two or three days while blood flowed out by gravity and then closed it when the drainage of blood ceased (9).

The belief in the importance of removing retained blood from a thoracic wound persisted in the seventeenth and eighteenth centuries, and led to the practice of wound sucking. The drummers were often the members of the military regiment who sucked the wound and then applied compresses and bandages (9). La Motte, a well-respected surgeon of the period, was initially skeptical of the ability of sucking to heal wounds of the chest and abdomen, but described an observation of a wound sucker in action which lead to his endorsement of the practice:

One day he was called to a young fellow, a common solider, who had been run through the breast with a fair lounge, in at the pap and out at the shoulder. After having examined the wound, and noticed the length of his antagonist’s sword, being well satisfied that the weapon had pierced the lungs, and gone quite across the breast; I saw the drummer of the regiment (who was the sucker on this occasion) do his business. He first sucked one wound, then turning his patient over, he sucked next the opposite wound; he then applied a piece of chewed paper upon each, and next day the soldier was seen walking in the streets. (10)

This technique for healing flesh wounds became so accepted that that noble and upper class men would bring wound suckers with them when they went to fight duels (9, 10).

In 1707, Dominique Anel described a method for sucking wounds with a silver tube attached to a piston syringe which replaced a human mouth. With this device, the surgeon could perform the procedure, and it was renamed aspiration. Anel went on to design a cannula which allowed a catheter to be introduced into the pleural space, instead of merely applied to the margins of the wound (9). Hermann Boerhaave, in Aphorisms of 1715, discussed thoracic wound management:

It is necessary to evacuate the extravasated blood [from the pleural cavity in traumatic hemothorax] by 1) posturing the patient and by appropriate exercises; 2) suction applied through a blunt-tipped flexible tube perforated laterally; 3) the injection of anticoagulant fluids; 4) enlarging the wound; 5) making a counterincision between the two lowest true ribs, four fingerbreadths from the vertebrae and the inferior scapular angle, using bistoury directed inferiorly, the incision placed between and parallel to the two ribs. (8)

This indicates that the ideas of postural drainage, intercostal placement of suction catheters for assisting drainage, and anticoagulation to assist drainage were present at least as early as the mid-eighteenth century (8). In 1771, Adamus Birkholz added a reservoir container into Anel’s suction line, creating an early Potain aspirator (9).

In spite of these advances, there was still a lack of consensus on the optimal initial management of thoracic wounds. In 1772, Valentin declared all wounds of the chest should be closed to minimize blood loss, but a counter opening could be made to evacuate the retained blood. Guthrie, an English military surgeon of the early 1800s, agreed. He closed wounds of the chest and watched for an increase in serous effusion three to five days after the injury, indicating that the bleeding had likely stopped. He then evacuated the blood with a trocar and cannula through a new opening or reopened the original wound. While Gurthrie knew that closure of the chest wound alleviated the patient’s struggle to breathe, his written works imply that he advocated wound closure to control hemorrhage from the lung. Larrey, a surgeon who treated Napoleon and a frequent antagonist of Guthrie, believed that there was a danger of renewed bleeding if attempts were made to evacuate effused blood less than nine days from the initial injury (9).

The concept of draining intrathoracic fluid was not confined to Europe. During the American Civil War surgeons used trocars placed in the chest to drain fluid in the pleural space, as described by Confederate surgeon Chisolm:

When the surgeon has recognized such collections as rapidly forming in the chest after gunshot wounds…an early evacuation will be required…an opening for the escape of the fluid should be made at the point which nature indicates, but, in cases of excessive effusion, any broad intercostal space, between the sixth and eighth ribs of the right, or between the seventh and ninth on the left, might be the point selected…a trocar and cannula, should be introduced at right angles to the chest and near the upper edge of the rib, towards its angle, in a line continuous with the posterior border of the armpit. (11)

It would still be almost a century before this practice gained widespread acceptance in surgery and made an appreciable difference in combat mortality. At the same time, the Union forces were experimenting with the use of airtight seals to impede air flow in open chest wounds (9).

The first description of a water-seal chest drainage system may be attributed to Playfair in 1873, in the treatment of a child with thoracic empyema. He initially performed four aspirations, but each time the pleural fluid re-accumulated. He then opened the abscess cavity and inserted a flexible tube of caoutchouc (India gum rubber), with the distal end in a vessel of water on the floor. The tube drained one to two ounces of pus daily without any entry of air into the pleura, and the patient’s clinical condition improved. The tube was eventually removed, allowing the free entrance of air, necessitating a counter-opening with placement of a drainage tube which was removed a week later (2, 12).

In 1875, Gotthard Bülau described his use of closed water-seal chest drainage to treat an empyema, as an alternative to the standard rib resection and open tube drainage in the acute phase or rib excision (saucerization) in the chronic phase (13). He used a trocar to puncture the pleural space then introduced a rubber catheter with a distal clamp. The weighted free end of the catheter was immersed in a bottle one-third full of antiseptic solution and unclamped, creating a siphon drainage apparatus and allowing pus to flow from the chest (13, 14). Most surgeons attributed deaths from thoracic empyema to infection and not superimposed respiratory compromise due to open pneumothorax, but Bülau, in many ways ahead of his time, emphasized the necessity of negative intrapleural pressure for re-expansion of a collapsed lung in the setting of thoracic empyema (13, 15). He understood that closed water seal drainage could facilitate lung re-expansion via the patient’s natural respiratory movements. Unfortunately, until mechanical ventilation was introduced, application of these principles was limited to the treatment of thoracic empyema (13).

In 1896, Paget, a London surgeon, published the first English text devoted solely to thoracic surgery. He discussed wounds to the chest caused by firearms compared to other mechanisms, writing “[o]f all penetrating wounds to the chest, it may be said that they must only be closed, provided the surgeon be at hand to reopen them, if necessary... Puncture and aspiration may be necessary” (8). Like Guthrie, he advocated closure as a mechanism for controlling hemorrhage, as opposed to supporting physiological breathing dynamics.

In spite of the tragic loss of human lives, war has traditionally contributed major breakthroughs in surgical care that have translated into improved care of civilians and combatants in future conflicts. This was not the case with tube thoracostomy, the acceptance of which was actually held back by military experience in World War I, II, and the Korean War (1). The invention of ether anesthesia and radiography in the previous century, followed by endotracheal intubation and blood transfusion in the early 1900s, should have enabled significant advancement in the treatment of penetrating chest wounds in World War I, but this did not happen. Mortality from chest trauma in World War I was 56%, with treatments including needle drainage of hemothorax, wound debridement, wound exploration for foreign body removal, and closure of open pneumothrax with sutures (1). Some advances in control of air flow in open chest wounds during World War I were the use of recently invented tampons and Morelli’s occlusive rubber cuffs, which allowed for closure and simultaneous suction drainage (9). By the end of World War I, post-thoracotomy evacuation of fluid in the pleural cavity was recognized as an important way to avoid infection, and the concept of a flutter valve for unidirectional air movement within a drainage tube was spreading, but tube thoracostomy was not widely used for treating hemothoraces or pneumothoraces (16).

World War I was unique from a thoracic pathology perspective because it coincided with the influenza epidemic of 1918, and the resultant crisis of streptococcal pneumonia and empyema (9, 13). This led to the creation of the Empyema Commission, composed of Dr. Graham, Dr. Dunham, and Captain Bell, with support from Dr. Kanavel. In February of 1918, a survey by the Commission demonstrated a mortality rate of 30% for empyema drainage in base hospitals. Based on claims by Duval in 1914 and Moynihan in 1917 that the thoracic cavity was as accessible to surgeons as the abdomen, the standard treatment for streptococcal empyema was rib resection with open tube drainage, resulting in death “quite regularly about half an hour after the operation” (9). Although immediate drainage of streptococcal pus was the standard of surgical care, Graham suspected that the open pneumothorax was a contributing factor in the deaths of these soldiers. Thus, the question of open versus closed management of penetrating chest wounds was still under discussion (9). Graham presented the Commission recommendations about the ideal timing of an operation, writing, “[w]hen the exudate has become frank pus instead of being merely serofibrinous…there is less danger of creating an open pneumothorax" (13). He interestingly noted, “[t]he 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” (13).

Contemporary German surgical methods included differential pressure chambers, but it is possible that tube drainage was perceived as a technique developed by the enemy and openly condemned by Duval and Moynihan (9, 13). Samuel Robinson was a civilian American surgeon who had been in close touch with the developments in Germany, including chambers with differential pressures (13) and had introduced vacuum pumps in 1910 to add suction to thoracic drainage (17). In the 1920s, Lilienthal used a pair of bottles to create a simpler method (18) and red rubber tubes were introduced (2). Lilienthal was also an early proponent of the use of closed pleural drainage in postoperative care in his writings about pulmonary resection for bronchiectasis, and in 1929 Brunn described post-lobectomy suction drainage of the pleural cavity (13).

At the start of World War II, restoration of lung function was the primary goal of thoracic wound treatment, with emphasis on wound debridement and pleural cavity drainage (1,16). It was believed that chest tube placement to remove blood and replace the blood with pressurized air could help to avoid the need for an open thoracotomy in patients with persistent intrathoracic bleeding, but needle aspiration was still recommended as first line treatment (11, 16). Following thoracotomy closure, a catheter was inserted into the eighth intercostal space and connected to a two-bottle water seal suction system. One-time thoracentesis continued as the treatment of penetrating chest trauma after the war, with chest tubes used only for brief periods in the presence of a continuous air leak (1).

In 1950, Monaldi suggested draining the thoracic cavity with a more superior approach at the second or third intercostal space (19, 20). The modern three chamber thoracic drainage system was first described by Howe in 1952 (21) but not widely employed at the time. In the Korean War (1950 to 1953), mortality decreased to 0.6%-1.9% of major thoracic trauma patients who survived to be evacuated and treated (22, 23). King urged repeated daily thoracentesis to avoid empyema, and stated that “the use of thoracotomy tube drainage for treatment of hemothorax resulted in a high incidence of complications” (22). Valle agreed, claiming 92% of patients who required decortication had been treated with closed intercostal drainage tubes, leading him to conclude, “[t]horacentesis is the most effective treatment for hemothorax…We feel that closed intercostal drainage is seldom necessary and often dangerous” (23). In 1958, the North Atlantic Treaty Organization recommended that “for penetrating traumatic hemothorax, the pleural space must be emptied as completely as possible by aspiration…closed intercostal drainage would be inadvisable,” reflecting the mainstream opinions of military surgeons (25). Rockey had a more favorable opinion of thoracotomy tubes. His protocol for obvious or suspected open wounds, chest wounds, and hemothoraces was: debridement, placement of thoracotomy tube through the wound, and aspiration of the pleural space, followed by maintenance of lung inflation during wound closure to the skin, and removal of the temporary thoracotomy tube. In the case of fluid re-accumulation, “a thoracotomy tube was inserted into the pleural space in a dependent position for continuous underwater drainage” (24).

In the late 1950s, Maloney (26) and Gray (27) discussed thoracotomy tubes and closed drainage techniques as equivalent in efficacy to repeated needle aspirations for preservation of lung function and avoidance of empyema in civilian patients with severe chest trauma. Maloney denounced the traditional replacement of aspirated pleural blood with air, reflecting his experience with penetrating chest trauma in the Los Angeles civilian population (26). There were refinements in tube placement technique, including anchoring the tube to the chest wall instead of the pleura during lobectomy (28), and advancements in the understanding of pulmonary physiology (29) during the 1950s as well.

In 1961, a catheter made of plastic was first introduced by Sherwood Medical (2). In 1963, Felton (30) advocated for constant, closed thoracotomy drainage with a 30 French Foley catheter and two-bottle suction system as the preferred treatment of pneumothorax and significant hemothorax. Two other civilian trauma surgeons, Gray from Atlanta (27) and Creech from New Orleans (31), agreed with Felton about the superiority of closed thoractomy catheter use for pleural space drainage. Maloney then extended closed thoracotomy drainage principles to patients suffering from blunt thoracic trauma (32). Based on his experience with thoracic trauma due to motor vehicle crashes and gun violence, Hughes agreed in 1965, advocating for “closed thoracostomy and underwater seal drainage for evaluation and treatment of hemothorax, particularly massive hemothorax” (33). This developing consensus from the civilian trauma surgeons would have a drastic effect on the standards of care in the Vietnam War.

McNamara (34) published a report on 547 thoracic injuries at a busy evacuation hospital in Vietnam, with the majority of those patients presenting with hemothorax, pneumothorax, or hemopneumothorax. He stated, “closed tube thoracostomy is the most effective method of treating most consequences of intrathoracic trauma… a major decision [is] which patient should have an open thoracotomy.” McNamara reported a mortality rate of 2.9%. The commentators in the invited discussion agreed, supporting the routine use of chest tubes in military and civilian thoracic trauma cases.

Although tube thoracostomy was finally accepted as the standard of care at the time of the Vietnam War, further technological developments have improved patient comfort and thoracostomy tube design. In 1968, Heimlich designed a flutter valve to attach to catheters and replace the cumbersome underwater drainage bottles. Its advantages included sterility, disposability, simplicity, safety in the event of disconnection, and allowance for patient ambulation (35, 36). A survey of thoracic surgeons in 1974 revealed a range of preferences for drainage systems including single or multiple bottles, plastic or glass units, various in-house designs, and showed that sampling ports and air leak meters were considered optional (37). In 1975, catheters were produced in sizes from 6French (F) to 40Fr in 2Fr increments; however, it was determined the most popular sizes were 28Fr, 32Fr, and 36Fr for adults and 16Fr, 20Fr, and 24Fr for children and production of the other sizes was halted (2).

Currently, chest tubes are made from clear plastic (vinyl or silastic). They have multiple side holes to allow effective drainage of fluid and air, and have centimeter markings to help note the depth of insertion. A radiopaque strip in the tube allows for easy visualization on chest radiography (38, 39). The use of TPA via the chest tube has expanded the therapeutic capability of this simple device so that now empyema and hemothorax can be often managed without an operation (40). Another advancement resulting in increased patient comfort is the use of “pigtail catheters,” which are small bore tubes that are less painful to insert and better tolerated once in place. They are inserted percutaneously using the Seldinger technique, and with image guidance can be placed accurately into a specific location within the pleural cavity (38, 41).

The current plastic three chamber single unit system allows for efficient collection of intrapleural fluid and evacuation of air. The introduction of a dry suction chamber to this system eliminates the bubbling sound made by the wet chambers while on suction (42). A miniature version with a smaller collection chamber, one-way valve to exit of air from the pleural space, dry suction chamber, and a shoulder strap allows a patient to ambulate easily and to be discharged from the hospital with the chest tube in place. This is a considerable advancement in patient safety and comfort compared to the original Heimlich valve (42, 43). Pleural drainage systems with digital quantification of air leaks and pleural pressure have recently been introduced as well (44, 45).

In recent years, the understanding of postoperative management of an air leak has been greatly advanced and the avoidance of suction on chest tubes after lung resection has allowed for quicker removal of the tubes and earlier discharge from hospital (46). In those with a prolonged air leak (greater than five to seven days), discharge from hospital with the tube in place and removal after two to four weeks once the air leak has resolved or still present, has decreased hospital length of stay, re-operation rate, and frustration surrounding the management of this condition (47).

While there have been major advancements in materials, sanitation, and understanding of pulmonary physiology and pathology, the principle of evacuation of pus, air, blood, and fluid from the pleural cavity using a drainage tube originated in ancient Greece and evolved over thousands of years. The simple chest tube should be treated with the respect and admiration bestowed upon it by its rich history.

References

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Comments

Great historical review. Would have expanded to include history of open and closed drainage procedures, as well as pneumonectomy drainage vs. no drainage with discussion of balanced drainage systems.
Wonderful scholarship. A great addition to the literature on history of surgery. I am currently working on a chapter entitled "A brief history of surgical treatment of lung cancer" and would love to reference this information. How should I cite your article? Congratulations on your achievement. Fred Grannis Jr. MD Clinical Professor of Surgery City of Hope National Medical Center Duarte CA fgrannis@coh.org
Excelente Trabajo, incluiria: 1.- Kaya SO. Were pneumothorax and its management known in 15th-century anatolia?. Tex Heart Inst J 2009;36(2):152-3). 2.- Batirel HF , Yüksel M .Thoracic surgery techniques of Serefeddin Sabuncuoğlu in the fifteenth century. Ann Thorac Surg 1997;63:575–7). 3.- José M. Galbis-Caravajal. Anotaciones históricas sobre el tratamiento de las heridas torácicas. Un lento y sangriento aprendizaje de la humanidad. http://www.jano.es/ficheros/sumarios/1/0/1727/29/00290033_LR.pdf
Excellent Work, would include: 1.- Kaya SO. Were pneumothorax and its management known in 15th-century anatolia ?. Tex Heart Inst J 2009; 36 (2): 152-3). 2.- Batirel HF, Yüksel M.Thoracic surgery techniques of Serefeddin Sabuncuoğlu in the fifteenth century. Ann Thorac Surg 1997; 63: 575-7). 3.- José M. Galbis-Caravajal. Historical notes on treatment Of the chest wounds. A slow and bloody learning of humanity. http://www.jano.es/files/sumarios/1/0/1727/29/00290033_LR.pdf

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