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