November 27, 1886] THE MEDICAL RECORD. 599 THE PRINCIPLES OF WOUND DRAINAGE AND THE USE OF HARD RUBBER DRAINS. By JOHN C. SCHAPPS, M.D., ASSOCIATE_SURGEON TO ST. MARY’S GENERAL HOSPITAL, BROOKLYN, N. Y. The importance of dryness as a condition of wound hygiene has had, during the last few years, an increasing recognition, as manifested by the number of recent dry dressings and implements for drainage. Of the former, perhaps, it may be true that perfection has been ap- proached ; but certainly not of the latter, since none of them has altogether supplanted the soft rubber tube, with all its imperfections. The mechanical principles operating to drain a fresh wound may be considered, in their natural sequence, under the following heads : I. The action of the tissues. II. Gravity. III. The action of the drain. I. There are occasionally to be removed from a wound, by drainage, before its healing can be accomplished, such solids as particles of bone, and very commonly such semisolids as blood-clots, flocculi of lymph, and detached shreds of tissue. The function of the first or serous dis- charge from a wounded surface is, as regards these loose fragments, simply that of a vehicle for their removal. Should it not suffice, and, on the other hand, should they fail to secure vital union with the neighboring tissues, their disintegration is accomplished after a time by the formation of pus, and their expulsion is thus rendered more certain. All foreign bodies in a wound, whether derived from the tissues themselves or introduced from without, tend in a varying degree to increase fluxion into it. Certain kinds, whose surfaces are rough and mobile, have also the property of causing coagulation of the fibrin contained in the wound exudations. The clots thus formed, those already existing, and bits of soft tissue when present, retain in themselves fluid which frequently prevents their permanent adhesion to adjacent parts and makes them very liable to become necrosed before they can escape. The importance of promptly removing these substances, or, at least, of depriving them of their liquid, as a preventive of suppuration, is evident. II. The current bearing the cast-off material is subject to (i.) its own vis a ter go, as fluid continues to be dis- charged from the tissues, to (ii.) the force of gravity, and possibly to (iii.) the capillary attraction caused by ap- proximated surfaces. But the last-named force alone doubtless never retains enough fluid to prevent healing. I he necessity of being guided by the law of gravity in determining the location and position of a drain needs no emphasis. III. Regarded as a foreign body, it is evident that the merits of a drain are inversely as its activity in causing fluxion, coagulation and obstruction of the dis- charges, and mechanical injury to the tissues by pres- sure or friction. Drains may be divided, according to the principles upon which they act, into two distinct classes—capillary and tubular. The former obstruct the egress of everything except fluid, and, because of their fibrous surfaces, are probably active in bringing about coagulation and fluxion. They have, however, the compensative merit of an absorbent power, in draining off the liquid which renders prejudicial the presence of soft, moist substances. Such a drain, forming the ex- tension of an absorbent dry dressing, may have large hygroscopic capacity. The dressing should, of course, be not merely a receptacle for discharges, but should have the power of absorbing from the drain, as the latter has of absorbing from the wound ; otherwise the drain itself becomes saturated and a source of danger. Cap- illary drains are less completely dependent upon the force of gravity than are those of tubular shape. An open or tubular drain is simply a tissue retractor to maintain a has no inherent power to take up to, 600 THE MEDICAL RECORD. [November 27, 1886 retain, or to transmit. Its contents may be impelled by accessions of fluid discharged from the tissues, but the sole principle which is relied upon for its operation is the force of gravity. Aside from its passivity as a foreign body, the value of a capillary drain depends upon its activity in absorbing fluid, that of a tubular drain upon the opportunity it furnishes solids, semisolids, and liquids to pass into and through it. There is a class of drains, including both the open form, as those of decalcified bone, and the capillary, as those of catgut, which from the nature of their material have compara- tively little potency in causing fluxion, coagulation, ob- struction, or mechanical injury. By the imbibition of liquid a gradually increasing soft, gelatinous layer is formed upon their surface, thus protecting the tissues with which they come in contact, and preventing the formation and deposit of fibrinous clots. The solu- ble portion of these drains finally becomes transformed into a homogeneous liquid which may either escape or be absorbed. A small amount of basement structure, sufficiently organized to readily take up vital connection with adjacent parts, remains. A soft drain of this kind is less prejudicial to a wound than a clot or similar sub- stance, because the latter cannot be liquefied except by a necrotic process, and, on the other hand, is not so highly organized, and therefore so ready to unite with the parts as is the structural base of an animal drain. The practical objection to these temporary affairs is their uncertainty. They may fail to maintain their exist- ence long enough, or may be too slow in softening. While it is unnecessary to discuss the advantages and disadvantages of each of the multitude of drains known to surgery, it is worthy of remark that the one probably in most general use—the soft rubber tube—has to a pe- culiar degree all unfavorable mechanical properties pos- sible, except that of rigidity, which, by the by, is not al- ways a disadvantage. Its surface is rough and its lat- eral openings are small, and usually angular. Their edges invite the coagulation of fibrin, and increasing depos- its frequently obstruct the apertures and may even oc- clude the lumen of the tube. The presence of such a body, with its load of disintegrating material, is one of the most frequent causes of failure to secure primary union. It is an open question whether, under these circum- stances, the admission of germs from without is a neces- sary factor in the production of suppuration. With a view to meeting the indications touched upon, I would call the attention of the profession to the possibil- ities of hard rubber as a material for wound drains, and present as examples the forms shown in the accompany- ing cuts. can be polished by means of crocus and oil. The makers, Messrs. Tiemann & Co., will furnish this instrument cut tc any length and finished, and also that one shown in Fig. 2. By the use of hot water or dry heat one of these drains may be given a permanent curve corresponding to that of the wound, and by twisting it while soft the width of the spiral opening may be modified. The end of the drain where the circumference is unbroken is placed externally in the wound. The spiral opening is not continued to the end of the drain, because the skin is thus liable to drop into it, and obstruct the tube. The two small holes are for the insertion of a hare-lip pin, safety pin, a stitch, or other means of securing the instrument in place. In all tubular drains the best openings are at the ends. A drain should therefore be as short as it can safely be used and in a wound with two openings should not pass through it from one to the other, but two drains should be introduced. This is especially important when one open- ing is superior and is for the purpose of admitting irrigat- ing fluid intended to reach all parts of the wound, and not merely to pass through the drains. The tube may be filled with catgut, horse-hair, or similar capillary material and the strands extended in all directions. They may be subsequently withdrawn, leaving the tube in situ, or may be left and the tube removeva.£ For this instrument the following merits are claimed: 1. As a foreign body it is comparatively harmless. The fact is well known that hard rubber pessaries cause much less vaginal secretion than those of soft rubber. Smooth, hard bodies, buried in the tissues, frequently become encysted, but soft substances usually give rise to ab- scess. It presents everywhere a polished surface ; its aperture is the largest possible, with the smallest possible extent of edge ; this edge is smooth, thin, and uninter- rupted by angle, crevice, or sharp turn, with the excep- tions of that at the end of the spiral opening and of the two small holes which are external to the wound. For these reasons it is not liable to cause coagulation, and the opportunity for coagula to adhere to and obstruct it is reduced to a minimum. Furthermore, by reason of its flexibility it cannot injure the tissues mechanically, except it be crowded into a situation where, by its mere presence, it interferes with the circulation. Its edges cannot sink into the soft parts, because of the width of the strip between them. 2. As it is unaffected by secre- tions or by chemical germicides it may be used again and again ad infinitum. 3. It cannot collapse. This property may prove valuable when considerable pressure by bandage is necessary to arrest oozing and prevent the formation of pockets. 4. From the thinnpcc nf be walls it is light, and has large capacity in proportion to its size. 5. Should granulations grow into it, its removal .vithout injuring them is easily accom- plished by a screw motion. The instrument shown in Fig. 2 and which, for distinction, may be called an inflexible drain, consists simply of a thin, hard rubber tube, upon one end of which is a rounded flange, while from the other, two opposite slits extend nearly the whole length of the instrument. Should occasion require, the blades on either side of the slit may be fixed, by the use of hot water, at any degree of diver- gence. This drain, like the preceding, is everywhere rounded and polished, and its only crevices are at the ends of the longitudinal slits. It is placed in a wound so that its flange is external, and is also provided with two small holes for the purpose of fixing it. The blades are quite yielding in the direction indicated by the dotted lines. It is made in the follow- ing sizes : No. 1, diameter, one-fourth inch ; length, one and one-half inch ; No. 2, diameter, five-sixteenths of an inch ; length, two inches ; No. 3, diameter, three-eighths of an inch ; length, two and one-half inches ; No. 4, di- Fig. i. That represented in Fig. i is flexible. It consists of a thin tube, the convex surface of which is perforated by a single long aperture, rounded at each extremity, and winding spirally about the tube but terminating a short distance from each end of it. The area of this opening, which is narrower than would appear from the cut, is about one-fourth that of the convex surface of the tube, exclusive of those portions where the cylinder is entire. Close to each end of the drain, and near together, are two small holes. The instruments are smooth and polished without, within, and on the edges. They are made eight inches long, and of four diameters, one-fourth, five-six- teenths, three-eighths, and seven-sixteenths of an inch externally, and are known as Nos. x, 2, 3, and 4 respec- tively. Each is intended to be divided into two drains, and is easily cut with knife or scissors, but it is better to soften the place where section is to be made. The flame of a match will suffice. The sharp edge made by cut- ting should be rounded with a fine emery cloth, and Fig. z. November 27, 1886] THE MEDICAL RECORD 601 ameter, seven-sixteenths of an inch; length, three inches. Probably other forms will be devised in which this material will be found a useful one for wound drains. In hip-joint abscess it has been well borne, and is easy of removal and replacement in the form of a round or flattened tube without lateral openings. Though holes of any size and shape may be made in hard rubber tub- ing, it should always be borne in mind that any drain should be as free as possible from irregularities of surface. 486 Bedford Avenue, Brooklyn, N. Y.