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CONTINUOUS SUCTION DRAINAGEWITH AN ACCOUNT OF A CASE OF BILATERAL

EMPYEMA TREATED BY IT

BY MAGNUS L. THOMSON, M.B. Aberd.MEDICAL REGISTRAR, SALFORD ROYAL HOSPITAL; LATE RESIDENTMEDICAL OFFICER, ROYAL MANCHESTER CHILDREN’S HOSPITAL

THE material required for the construction of theapparatus (Fig. 1) consists of : two Winchesterbottles (B and c), a drainage bottle (A), a glassirrigating reservoir (D), three rubber stoppers to fitbottles A, B, and c, some lengths of glass tubing, aY-shaped glass connexion, a T-shaped glass con-

nexion, rubber pressure tubing, and some spring clips.The drainage bottle (A) is placed on a table at the

bedside, together with one of the Winchesters (B),while the irrigating reservoir (D) is placed on anupright stand attached to the table. The secondWinchester (c) is placed on the floor beside thetable. Bottle A is fitted with a rubber stopperthrough which pass two short lengths of glass tubing.Bottles B and c are similarly fitted with rubberstoppers through each of which pass one long and oneshort length of glass tubing. Bottles Band c act as

syphon bottles-water being made to syphon fromB into c. The suction of air into B as the waterleaves it provides the motive force of the apparatus.This force is supplied to the pleural cavity through acatheter which is inserted between the ribs. Bottle Aacts as a drainage trap, while a side connexion fromthe catheter, to the reservoir, D, enables intermittentirrigation to be carried out. Communication betweenthe various units of the system is effected by rubbertubing.The end of the catheter is attached to a Y-shaped glass

connexion, one limb of which is connected by rubbertubing to one of the glass tubes passing through thestopper of bottle A, while a second length of rubber tubing

FIG. I.-The apparatus (described in text).

attaches the other limb to the reservoir D.Bottle A is of the suction type-i.e., it con-tains a glass outlet at the foot. Over thisoutlet is attached a short length of rubbertubing of sufficiently wide diameter with its free endclosed by a spring clip. From the second of the glasstubes, passing through the stopper of bottle A, a short

length of rubber tubing makes connexion to one end ofthe horizontal limb of a T-shaped glass connexion. Theother end of the horizontal limb of the T connexion isattached by a short length of rubber tubing to the shortglass tube passing through the stopper of bottle B. Tothe dependent limb of the T connexion is attached ashort length of rubber tubing, which acts as an air-leaktube. During suction this tube is clipped. The longglass tube passing through the stopper of bottle B isattached by a length of rubber tubing to the long glasstube of bottle c. Bottle B is filled with water. Some

disinfectant fluid is run into bottle A. Spring clips aredistributed as shown in the diagram. Seven clips are

required.TECHNIQUE

The system is essentially a closed one. Thesmallest air-leak in any part of the apparatus willeither render the apparatus useless or so diminish theforce of the suction in the pleural cavity as to makethe drainage inefficient. In our earlier experiencethe repeated development of such leaks provided themain difficulty in maintaining effective suction. The

apparatus, as

described, is de-

signed to avoidthis difficulty, andby using the fol-lowing techniqueit has provedthoroughly effi-cient (Fig. 2).

Bottles A and Bare sealed in the

following fashion.The glass tubes

passing through thestoppers are not

right - angled butare simple straighttubes inserted

through holes boredin the rubber stop-pers. The rubber

tubing attached tothem is pushed over their free ends until it comes incontact with the top of the rubber stopper. Round theneck of each bottle a broad cuff of adhesive tape is appliedinto which is poured melted wax. On setting, this effec-tively seals the joints (a) between the stopper and thebottle, (b) between the glass tubes and the stopper, (c)between the rubber tubing and the glass tubing enteringthe bottle.As drainage proceeds, the water in bottle B slowly

syphons into bottle c, and after an interval of some sixto ten hours will require to be returned to bottle B toallow suction to continue. To carry out this manoeuvre

clip 4 is closed and, with clips 5 and 6 open, bottle c isheld above the level of bottle B and the water syphonedback into B. The air in B escapes through the openair-leak tube attached to the dependent limb of theT connexion between bottle A and bottle B.The drainage bottle A will also require to be emptied

after it has filled with drainage fluid. To do this clip 3and clip 5 are closed ; clip 4, clip 6, and clip 7 opened.The drainage then runs out through the outlet opening ofbottle A. When bottle A has emptied, a little disinfectantfluid is run in. Clip 6 and clip 7 are then closed and

clips 5 and 3 opened. In this way it is possible to keepthe apparatus working without disturbing the sealedbottles A and B.

Air leaks may occur where rubber tubing is attached toglass connexions. In this case some narrow adhesivetape bound over the leaking union effectively closes it.The joint between the drainage tubing and the glassoutflow opening, at the foot of bottle A, must also beairtight. This can be conveniently sealed by painting theconnexion with varnish.

The apparatus having been carefully prepared andtested to exclude air leaks, the catheter is insertedinto the pleural cavity. Pressure rubber tubingshould be used throughout.

Insertion of the catheter.-The catheter used is aNo. 10 Dowse’s type of self-retaining catheter. LTnderlocal anaesthesia an incision is made in the skin, anda trocar and cannula, just large enough to admitthe catheter, is inserted into the empyema cavity.The trocar is then withdrawn and the catheterinserted by means of an introducer. The introducer

FIG. 2.-Diagram showing the way inwhich leakage at the mouth of thebottle is prevented.

1436

is withdrawn and the cannularemoved. Precautions are takento prevent air entering thechest.

The dre8sing.-The dressing atthe chest wall must be made air-

tight. To do this, pledgets of

gauze or cotton-wool are soakedin collodion and applied in suc-

cessive thin layers round thecatheter. The dressing shouldhave a diameter of about threeinches. Collodium acetonum isused as this sets quickly and

efficiently. A bandage is appliedto hold the dressing in place. Thecatheter is then connected to the

apparatus and suction coii-i-

menced.

111 a nageme nt during t1’eatment.-During suction all the spring clipsare left open except clips 2, 6, and7. No irrigation is carried out for at least six hoursafter the dressing has been applied. Subsequently theempyema cavity is irrigated every two hours by dayand every three hours by night. During irrigationclip 3 is shut and clips 1 and 2 open. Dakin’s solutionis used for the irrigating fluid and the level of fluid inthe reservoir D should never be more than eighteeninches above the opening in the chest wall. Irrigationis carried out more frequently if necessary, the mainindication being to maintain free drainage.The quantity of fluid run in is controlled by its

effect on the patient. Coughing or pain is an indica-tion to stop. Should the patient prove unusuallysensitive, the fluid should be warmed and run in veryslowly. The progress of the case may be observedby comparing the quantity of Dakin’s solution usedwith the quantity of drainage recovered from thebottle A each day. For this purpose it is an advan-tage to have the reservoir D graduated. It is advis-able to keep the side connexion to the reservoir Das near to the catheter as possible. In this way theminimum of pus is washed back into the empyemacavity during irrigation.The following difficulties may be encountered :—

(1) Blockage of the catheter.-Milking the rubber tubing

FIG. 3.-Bilateral continuous suction drainage in progress.

FIG. 4.—Temperature chart. 1 = closed drainage started (left side). 2 =closeddrainage started (right side). 3= catheter removed from left side. 4 =wouiadon left side closed without drainage. 5 = catheter removed from right side.6=patient allowed up. 7 =patient walking. 8 =wound on right side closedwithout drainage.

either towards or away from the chest usually overcomesthis difficulty. Should it fail it may be necessary todisconnect the catheter and syringe it through with alittle Dakin’s solution.

(2) Air leaks in the apparatus.-These do not occur ifthe apparatus has been carefully constructed. It may be

necessary to reseal one of the bottles. The leak is locatedby first closing clip 5 and observing if the water level inB drops. If it does, bottle B is resealed. The same;procedure is followed with clip 5 open and clip 4 closed;and again, with clip 4 and clip 5 open and clip 3 closed.

(3) Non-airtight dressing at the chest wall.-The dressingmust be replaced and irrigation discontinued for six hours.

(4) Restlessness of the patient.-The presence of thecatheter is usually well tolerated and restlessness is readilycontrolled by sedatives.

Two complications must be considered. (1) Blood.stained washings : if the washings are only tmgedwith blood, the suction is reduced by raising bottle cone or two feet from the floor ; if there is muchhaemorrhage, irrigation is stopped for 24 hours.(2) Infection of the skin : the dressing is removedand fomentations applied round the catheter until theinflammation has subsided.

Advantages and disadvantages.-The signal of successis a rapid and maintained drop in temperature and

respirations. Unless ex-

plained by acute processesin the lungs or elsewhere,every rise of temperatureor of the respiratory ratedemands the most careful

investigation. Free and

complete drainage must bemaintained.The advantages of

this method scarcely re-

quire enumeration. Theinsertion of the catheteris a minor procedurewhich causes little dis-turbance to the patientand can be carried out inpatients who are acutelyill. Frequent and painfuldressings are avoided. Thedisadvantages which havebrought the methodinto some disfavour havemainly resulted fromthe use of an appara-tus which is incompletely

1437

airtight. The most careful nursing is essential. Byfollowing the technique described, the apparatus hasbeen proved entirely trustworthy and the course ofthe illness remarkably uneventful in the cases treatedat the Children’s Hospital by this method. Thefollowing is an illustration.

CASE REPORT

The patient, a girl aged 8 years, was admitted to thehospital on Feb. 22nd. The parents informed us thatshe had always been " chesty " but for the past five weekshad been ill with pneumonia. The child was pale andpoorly, with rapid and embarrassed respirations. Hertemperature was 101° and she showed evidence of an acutetoxaemia.

Physical examination revealed signs of a considerableeffusion of fluid into the left pleural sac, with some displace-ment of the heart to the right. Resonance was impairedat the right base and there were numerous bronchitis signsover the right lung. Aspiration of the left pleural sacshowed thick pus in which pneumococci were found.On the evening of admission a catheter was inserted into

the left pleural sac and continuous suction drainagecommenced. The temperature soon fell and the patientremained practically afebrile until ten days later, when theevening temperature rose to 100°. As drainage of the leftpleural sac had proceeded satisfactorily and the dullnessat the right base had increased, the right pleural cavitywas explored and pus aspirated, which contained pneumo-cocci. On the morning of March 4th a second catheterwas inserted into the right pleural cavity and suctiondrainage of the right side commenced. The patientspeedily became afebrile and her condition improvedrapidly. The photograph (Fig. 3) shows the apparatus inaction. On March 10th, seventeen days after its insertion,the catheter was removed from the left pleural cavity,drainage on this side having become negligible. Three dayslater the wound became closed with a healthy scab. OnMarch 14th, eleven days after its insertion, the catheter wasremoved from the right pleural cavity and four days laterthe wound became closed with a healthy scab. OnMarch 15th, three weeks after admission, the patient wasallowed up and next day was permitted to walk a few steps.During the afebrile stages of the disease, lung expansion

was encouraged by the use of blow-bottles. As the

appetite improved she was given a high protein diet,supplemented with cod-liver oil. A radiogram taken onMarch 12th showed no evidence of fluid in either pleural sac.

After three and a half weeks in hospital, though stillthin, the patient was in remarkably good general condition,had a ravenous appetite, and showed no physical signsapart from some evidence of bronchitis over the left lowerlobe. This appeared to be chronic and the cure was

considered to be complete.Reference to the clinical chart (Fig. 4) indicates the

degree of efficiency of the drainage.I am indebted to Dr. C. P. Lapage for his kind

permission to publish the above case ; to Mr. J. D.McEachern for the main principles of the technique ;to Mr. D’Arcy McCrea for a practical introduction tothe method ; to Mr. Teesdale for his excellent photo-graph ; and to the nursing staff, to whom much of thesuccess of the treatment in the case was due.

BIBLIOGRAPHY1. McEachern, J. D.: Brit. Jour. Surg., 1933, xx., 653.2. „ „ : Brit. Med. Jour., 1931, i., 389.3. Edwards, A. T. THE LANCET, 1931, ii., 1126.4. Tomainoli, M.: Amer. Jour. Surg., 1933, xxi., 289.

" LOCKING CHILDREN IN."-Under this title thedirector of the National Society for the Prevention of

Cruelty to Children draws attention to "the increasingpractice of leaving children locked up in’ the housealone." Apart from actual fatalities resulting fromthis practice there are, he points out, serious mentaland psychological risks attached to it. In all cases reportedto them the Society’s inspectors have been able to showthat with goodwill and management these risks can beavoided.

THE PERIODICITY OF MICROFILARIA

BANCROFTI

BY CLAYTON LANE, M.D. Lond.LIEUT.-COLONEL, I.M.S. (RETD.)

Dr. G. Carmichael Low and Dr. P. H. Manson-Bahrhave reported (1934) the careful, accurate, anddevoted observations of A. H. Walters carried outin London on a filarial lascar, by means of two-hourlycounts of the numbers of JJ!iCJ’ofilaria bancroftipresent in the same quantities of his peripheral blood.After comments they reach the following conclusions :"For the moment we, just as Manson did some 50years ago, believe that filarial periodicity is best

explained by parturition going on more or less

continuously, the young being, as Manson put it,nearly constantly carried along the lymphatics andthoracic duct to the blood, while the excess thatwould in time take place is checked and kept moreor less constant by a mortality amongst the olderand effete embryos." Against this view, here

restated, I have already (1929) brought forward factsand considerations which best explain this periodicityby a simultaneous timing of the cycle of parturitionof all live female worms, so that broods of embryosare simultaneously poured into the blood, and rapidlyremoved therefrom and destroyed. Most of the pointsin that line of argument have been accorded nocomment by these writers ; yet I will extend tothem the courtesy of a detailed consideration of theviews expressed in their last paper.

In the arguments they use, assumption has anundue place ; and it is in the interest of tropicalmedicine that this should be made clear. For if

large numbers of micronlariae are destroyed daily,the organ or tissue which does this is being subjectedto continuous overwork, with loss of that potentialreserve on which the body should be able to fallback in times of stress; and there is the likelihood,or certainty, that it will eventually suffer permanentstructural change. In other words the matter isnot one of mere academic interest, but affects thedaily lives of hundreds of thousands of people.Having found that, judging by blood samples of

the same size taken every two hours, night and day,the total number of micronlarise was much the sameover 24 hours whether periodicity was of normaldistribution or had been disturbed by altering thesleeping hours of the host, these writers concludewith emphasising italics that this finding pointsstrongly to daily migration and reappearance of thesame undamaged embryos rather than to the regulardeath and exact numerical parturition of embryosby the adult female worm or worms. But one knowson the one hand by the 17-year-old work of WarringtonYorke and B. Blacklock (1917) that a microfilarialtotal of this sort need not be so exact, as is here

reported, when microfilarial periodicity is changed bymere altering of the hours of sleep ; and on the otherhand that when a hookworm or trichostrongylus caseis followed day by day, the number of eggs in thefaeces has a like rough equality. With the last wormsthe rough constancy is manifestly due to parturition ;accordingly the emphatic assumption that the

opposite is the case in filariasis has but a weak founda-tion. The writers make a return to the subject inthese words : "This [constancy], we hold, indicatesa more or less constant stream of embryos emergingfrom the uteri of the adult worm daily, with a

corresponding destruction constantly going on, other-