Surgical drainage, the origins and where we are today

The use of drains in surgery has a rich history. Since ancient times, drainage has experienced a long progress, and its development has continued all the way to the present era. Both the indications for drainage and the material of surgical drains have changed over the last 2500 years. Indeed, drainage as we know today, was not always a practice so common or generally so well accepted, as it is today. The current concept of surgical drainage has witnessed not only periods of success, but also dead ends and mistakes of both science and medicine.

The treatment of wounds during World War I

The First World War was a huge tragedy for mankind, but, paradoxically, it represented a source of significant progress in a broad series of human activities, including medicine, since it forced physicians to improve their knowledge in the treatment of a large number of wounded soldiers. The use of heavy artillery and machine guns, as well as chemical warfare, caused very serious and life-threatening lesions and wounds. The most frequent causes of death were not mainly related to gunshot wounds, but rather to fractures, tetanus and septic complications of infectious diseases. In the first part of this article, we describe the surgical procedures and medical therapies carried out by Italian physicians during the First World War, with the aim of treating wounded soldiers in this pre-antibiotic era. Antibacterial solutions, such as those of Dakin-Carrel and sodium hypochlorite and boric acid, the tincture of iodine as well as the surgical and dressing approaches and techniques used to remove pus from wounds, such as ignipuncture and thermocautery or lamellar drainage are reported in detail. In the second part of the paper, the organization of the Italian military hospitals network, the systems and tools useful to transport wounded soldiers both in the front lines and in the rear is amply discussed. In addition, the number of soldiers enrolling, and those dying, wounded or missing during the Great War on the Italian front is estimated.

[Artificial drainage devices--history, indications]

Glaucoma is a degenerative optic neuropathy progressive, multifactorial, which can lead to blindness. Blindness in patients with glaucoma is defined as visual field reduction below 10 degrees. Artificial drainage systems are a solution for refractory to medication, laser treatment or conventional surgery. Used by over 100 years, improved with good surgical technique and careful patient follow-up surgery, postoperative results are satisfactory.

[A history of joint puncture and injection]

Up until the middle of the 20th century joint puncture was considered a dangerous surgical intervention performed primarily to drain pus. The differential diagnostic significance of synovial analysis only became clear in the second half of the 20th century. Thus it became possible to reliably distinguish between inflammatory and non-inflammatory diseases, and establish whether arthritides are bacterial or crystal-induced. Attempts to inject disinfecting or anti-inflammatory solutions into the joint go back to the end of the 19th century. In the mid 20th century, cortisone became the panacea of intraarticular therapy. After surgeons at the end of the 19th century succeeded in surgically removing the inflamed synovium, internal medicine specialists attempted to destroy the synovial membrane by injecting it with various chemicals around the mid 20th century; however, hardly any of these substances survived. Only with "internal radiation" by injecting radionuclides was a breakthrough seen in the middle of the 20th century. Since then radiosynoviorthesis and synovialectomy have become standard methods in the treatment of chronic inflammatory joint disease.

Nasogastric tubes: an historical context

Nurses commonly care for patients with nasogastric tubes. Many authors have addressed the management of nasogastric tubes; however, discussion rarely considers the historical perspective. The purpose of this article is to provide an historical context on nasogastric tubes.

The first description of a device for repeated external ventricular drainage in the treatment of congenital hydrocephalus, invented in 1744 by Claude-Nicolas Le Cat

An 18th century report of a device for repeated extracranial drainage of cerebrospinal fluid in the treatment of congenital hydrocephalus is reviewed. On 15th October 1744, the French surgeon Claude-Nicolas Le Cat (1700-1768) introduced a specially invented canula into the lateral ventricle of a newborn boy with hydrocephalus. The canula was used as a tap and was left in place for 5 days, until the death of the child. This procedure should be seen as the first documented description of a device for repeated ventricular taps in the treatment of hydrocephalus.

[From the history of wound care]

Wound care in ancient times was based on many techniques: Bandages soaked with antibiotics, Sutures continuous or in separate stitches, apply of poultices around the wounds, honey and propolis as antibiotics in the treatment of wounds, surgical drainage of pus with a piece of tin pipe etc. The oldest wound clamp is shown with the jaws of ants holding together the edges of a wound. Finally are discussed the cauterization and the principles of Antisepsis and Asepsis.

Techniques of pneumonectomy. Drainage after pneumonectomy

After most pneumonectomies, the pleural space can be safely closed without drainage. If a chest tube must be used, a balanced drainage system is recommended. This article specifically addresses some of the controversial issues in the early management of the postpneumonectomy space. It also describes the indications, advantages, and disadvantages of drainage and the methods commonly used for this purpose.

Direct cholangiography and biliary drainage

Direct cholangiography by percutaneous transhepatic cholangiography or endoscopic retrograde cholangiography has greatly improved diagnostic work-up of patients with known or suspected biliary obstruction. These diagnostic procedures were introduced in Denmark in the early 1970s, and technical refinements and clinical research of the methods were initiated. The Danish contribution led to definition of indications for direct cholangiography and general acceptance of the methods in daily clinical practice; nationally as well as internationally. The transhepatic cholangiography with selective catheterization of the biliary ducts permitted external drainage of obstructed ducts. The disadvantages of this technique inspired the innovation of internal biliary drainage and the invention of the biliary endoprosthesis. The endoscopic approach to the biliary tract and the technical improvements of accessory instruments led to the early introduction of therapeutic procedures, i.e. papillotomy, stone removal, biliary drainage and treatment of strictures and post-traumatic lesions. Experimental and clinical research with endoprostheses improved their function and prevented dislodgment. Clinical research documented that biliary drainage by endoprosthesis is a valuable alternative to surgical bypass in patients with inoperable biliary obstructions. Endoscopic therapeutic procedures for common bile duct stones have almost replaced conventional surgical treatment. Endoluminal imaging techniques are under evaluation and may contribute to future improvements.

History of urethral catheters and their balloons: drainage, anchorage, dilation, and hemostasis

Male urethral catheterization, as practiced in early Greece, was made possible by a sound knowledge of anatomy. It has been preserved by written tradition and advanced by the development of new materials. Balloon dilation, conceived and practiced more than 160 years ago by urologists, has undergone a similar cycle. Some useful ideas, once conceived, have been forgotten and have surfaced again, decades, sometimes centuries, later as new inventions.

Gotthard Bülau and closed water-seal drainage for empyema, 1875-1891

Optimal treatment of pleural empyema remains controversial to the present day. In the preantibiotic era, surgical thinking favored early and aggressive drainage of closed-space infections, but the dynamics of the pleural space were poorly understood and open pneumothorax 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 drainage only after loculation had occurred. Paradoxically, closed water-seal drainage for empyema had been used by a German internist, Gotthard Bülau, 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 Bülau probably could not foresee the future importance of his method to surgery.

Acute putrid abscess of the lung. By Harold Neuhof and Arthur SW Touroff. 1936

This 51-year-old report detailed the principles of operative treatment of acute putrid abscess of the lung in the era prior to antibiotic availability. The technical aspects of the surgical approach advocated by Neuhof and Touroff were based on careful clinical and pathological review. In an era of increasing immunosuppressive therapy, both for transplantation and the treatment of malignant disease plus the emergence of new diseases such as acquired immune deficiency disease, there may be a re-emergence of lung abscess in patients too sick to undergo resection. Hence, the technique has present applicability.

Concatenations

Concatenations, linkings of events and ideas, are demonstrated to show the progress of thoracic surgery. The development of our knowledge of pulmonary anatomy, pleural drainage, and thoracic anesthesia, independently and collectively, has proven invaluable in the current successful surgical treatment of many pulmonary diseases.

Samuel Robinson, pioneer thoracic surgeon (1875-1947)

Sam Robinson was born in Augusta, ME, in 1875. A graduate of Harvard Medical School, and of the Massachusetts General Hospital (MGH), he worked in the laboratory of Walter Cannon. While a junior at MGH he spent four months abroad with Ferdinand Sauerbruch. He returned to Boston and remained there until 1912, performing his first successful lobectomy for bronchiectasis in 1909. He made important contributions to the management of pneumothorax during operation, notably Sam Robinson's box. In 1912 he moved to Clifton Springs, NY. From 1915 to 1917 he was the first Chief of Thoracic Surgery at the Mayo Clinic. Illness, probably bronchiectasis, led him to abandon academic thoracic surgery in 1918 and retire to Santa Barbara, CA, where he practiced general surgery until 1947. He was President of the Association for Thoracic Surgery in 1922. In addition to the use of positive pressure and early resections, his contributions include artificial pneumothorax for tuberculosis and management of acute and chronic empyema. His colorful writings provide a vivid picture of the early days of our specialty.

The past 25 years of surgery

The past 25 years have seen an explosion in interest and progress in the diagnosis and treatment of vitreoretinal diseases, especially retinal detachments. This progress has paid high dividends in the prevention of blindness and the clinical care of patients. The major advances during this period are the development of a binocular stereoscopic indirect ophthalmoscope combined with scleral depression, the introduction of a scleral buckling procedure to close retinal breaks, the development of instruments capable of producing controlled focal irritation in the ocular fundus, and the advent of direct surgical removal of the vitreous.

The surgical management of subphrenic abscess: a historical study

This paper is a study of the evolution of the management of subphrenic abscess from the earliest reports to the present day. Its purpose is to compare and contrast the attitudes and practices established during the earlier years with those of the present, in particular in relation to changes consequent on the introduction of antibiotics.