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BONE-MARROW GRAFTS IN LEUKÆMIA
497 Evacuation of an abscess leaves behind a pyogenic cavity which continues to produce infected material. Closed drainage prevents the dissemination of infection, at the same time keeping the cavity empty and reducing its size. In this group of cases we use closed drainage with suction, employing polyethylene bottles. No originality is claimed for the method but it has proved so successful that we feel its advantages should be more widely known. For the drainage tube we use a plain rubber or portex catheter of approximately size 10 (English gauge). To this is attached a light polyethylene bottle which has a screw-on cap with a tapering nozzle, also made of polyethylene. The walls of the bottle are lightly compressed as the nozzle is inserted into the end of the catheter, so that a low negative pressure is created, sufficient to draw pus, blood, or serum from the far end of the catheter into the bottle. The advantages of this method are numerous: remain clean and need not be changed in the early postwound is most tender. Economy in dressing materials and nursing time is considerable and bacterial dissemination is reduced. It is a simple matter to check at any time that the system is function-
Dressings
operative days when the
ing efficiently. One has a sterile and immediately visual method of assessing when the drain might have fully served its purpose and be withdrawn without any need to disturb the dressing. The quantity of drainage is measurable, and can be recorded on the patient’s fluid chart when appreciable in amount. The bottles are made of low density polyethylene and are very light to
handle.
are cheap and can be used many times. This suction drain operates continuously and silently with very little supervision. The patient can be fully ambulant while suction is maintained.
They
Attention to the following practical points is important. The drain tubing must be firm enough so that it will not collapse with the negative pressure. For this reason we use a Jacques or Harris catheter with several extra holes cut. The fluted proximal end allows easier insertion of the nozzle and can be
BONE-MARROW GRAFTS IN LEUKÆMIA SIR,-In the discussion of the use of autologous marrow grafts in your leading article of Jan. 23 mention is made of three of our cases of leukxmia in which we employed total-body irradiation and infusion with autologous 1 It might be of marrow obtained during a remission. interest to add the follow-up of the patient in whom a remission was achieved by this procedure. The patient, a 2-year-old girl, remained well until the 84th day after irradiation, when the liver, spleen, and lymph-nodes were observed to be enlarged, and a bone-marrow aspirate showed recurrence of leukaemia. A-methopterin therapy, to which she had become refractory before irradiation, was reinstituted, with some regression in the size of the lymphnodes and a fall in the white-cell count. However, she died while being given a blood-transfusion 102 days after irradiation. Postmortem examination showed leukaemic involvement of the liver, spleen, lymph-nodes, bone-marrow, and kidneys. Several walled-off splenic abscesses caused by Staphylococcus aureus were present. In addition to involvement by leukxmic infiltrates the lymph-nodes showed scattered follicles, and the stomach and intestines contained many follicles with germinal centres.
prominent lymphoid
Although a remission was obtained in this one case, we believe that further investigation is necessary to determine whether bone-marrow grafts are of practical value in the treatment of leukaemia. LEONARD ATKINS JOSEPH J. MCGOVERN Massachusetts General Hospital, Boston.
PAUL S. RUSSELL EDWARD W. WEBSTER.
cut to
DISCHARGE FROM A HOSPITAL VACUUM SUCTION SYSTEM SIR,-A piped vacuum system is being installed in New Guy’s House, which is now under construction. This department was asked to advise whether there was any danger from the exhaust from such a system, which might collect pathogenic organisms, particularly antibiotic-resistant staphylococci, and discharge them into the atmosphere. As inquiry revealed no information on this matter, it was decided to investigate an existing vacuum system. That at the Royal Marsden Hospital
a
was
the size required for a secure fit. The catheter is held by double suture inserted close on each side (see figure) and it is important to avoid puncturing the catheter with the needle. It is essential to avoid over-compression of the bottle especially after repeated use, otherwise it will become kinked and will not re-expand. The bottle interior is sterilised by filling with a 1 in 20 solution of carbolic and there has been no sepsis attributable to the use of this method. Two sizes of bottle (4 oz. and 10 oz.) have been used, the smaller size being suitable for most cases. Experiment has shown that both sizes of bottle can draw up a column of water 4 mm. in diameter to a height of 100 cm. After repeated use the polyethylene tends to harden and the suction power is reduced. This negative pressure has not given rise to any complications in practice and compares favourably with the use of many electric pumps which may go
building up an ever-increasing negative pressure. Moreover, they effectively immobilise the patient and may cause considerable annoyance if the pump is noisy. The polyethylene bottles, on the other hand, are eminently portable and silent. Despite the limited calibre of the catheter and dispenser spout, there has been no tendency to blockage. We are at present experimenting with nozzle fittings of different shape The screw-on top is being retained, however, and size. because of the access it allows for cleaning. on
I
am
to Mr. J. Hutchison for much helpful criticism and Mr. P. S. Waldie, A.R.P.S. for the diagram.
grateful
advice, and
to
Stobhill General
Hospital, Glasgow.
F. T. CROSSLING.
selected.
It was installed in 1948 and consists of suction points, in three operating-theatres, a reservoir tank, and a pump in the basement with a discharge pipe to a basement yard. The vacuum is maintained between 15 and 25 in. of mercury. Through the cooperation of the Royal Marsden Hospital and British Oxygen Gases Ltd., the following investigations were carried out:
(1) Three sections of pipe were cut out-near a suction point, in the main vacuum line from the theatre floor, and just before the tank. The inside of each pipe was found to be dry and macroscopically clean. Swabs were taken from these three sites and from the inside of the tank. Direct plating produced no growth, and enrichment in broth grew Staphylococcus albus and diphtheroids from two swabs only. (2)
The effluent air was sampled by passing it through a plug of sterile alginate wool of approximately 1 cm. diameter which was then dissolved in a 1%sodium hexametaphosphate solution containing 10% horse serum. The resulting solution was cultured. Two tests were made on different days in which 150 and 200 litres of air (as measured by a gas meter) respectively were pumped. On the first occasion the vacuum was broken at the entrance to the tank; no organisms were recovered. On the second occasion the vacuum was broken at a suction point in a theatre so that air was drawn through most of the system. Staph. albus was isolated, on enrichment only. Quantitative control tests using Staph. aureus showed that the solvent used was not significantly inhibitoiy. 1. New
Engl. J. Med. 1959, 260,
675.
Dressings
operative days when the
ing efficiently. One has a sterile and immediately visual method of assessing when the drain might have fully served its purpose and be withdrawn without any need to disturb the dressing. The quantity of drainage is measurable, and can be recorded on the patient’s fluid chart when appreciable in amount. The bottles are made of low density polyethylene and are very light to
handle.
are cheap and can be used many times. This suction drain operates continuously and silently with very little supervision. The patient can be fully ambulant while suction is maintained.
They
Attention to the following practical points is important. The drain tubing must be firm enough so that it will not collapse with the negative pressure. For this reason we use a Jacques or Harris catheter with several extra holes cut. The fluted proximal end allows easier insertion of the nozzle and can be
BONE-MARROW GRAFTS IN LEUKÆMIA SIR,-In the discussion of the use of autologous marrow grafts in your leading article of Jan. 23 mention is made of three of our cases of leukxmia in which we employed total-body irradiation and infusion with autologous 1 It might be of marrow obtained during a remission. interest to add the follow-up of the patient in whom a remission was achieved by this procedure. The patient, a 2-year-old girl, remained well until the 84th day after irradiation, when the liver, spleen, and lymph-nodes were observed to be enlarged, and a bone-marrow aspirate showed recurrence of leukaemia. A-methopterin therapy, to which she had become refractory before irradiation, was reinstituted, with some regression in the size of the lymphnodes and a fall in the white-cell count. However, she died while being given a blood-transfusion 102 days after irradiation. Postmortem examination showed leukaemic involvement of the liver, spleen, lymph-nodes, bone-marrow, and kidneys. Several walled-off splenic abscesses caused by Staphylococcus aureus were present. In addition to involvement by leukxmic infiltrates the lymph-nodes showed scattered follicles, and the stomach and intestines contained many follicles with germinal centres.
prominent lymphoid
Although a remission was obtained in this one case, we believe that further investigation is necessary to determine whether bone-marrow grafts are of practical value in the treatment of leukaemia. LEONARD ATKINS JOSEPH J. MCGOVERN Massachusetts General Hospital, Boston.
PAUL S. RUSSELL EDWARD W. WEBSTER.
cut to
DISCHARGE FROM A HOSPITAL VACUUM SUCTION SYSTEM SIR,-A piped vacuum system is being installed in New Guy’s House, which is now under construction. This department was asked to advise whether there was any danger from the exhaust from such a system, which might collect pathogenic organisms, particularly antibiotic-resistant staphylococci, and discharge them into the atmosphere. As inquiry revealed no information on this matter, it was decided to investigate an existing vacuum system. That at the Royal Marsden Hospital
a
was
the size required for a secure fit. The catheter is held by double suture inserted close on each side (see figure) and it is important to avoid puncturing the catheter with the needle. It is essential to avoid over-compression of the bottle especially after repeated use, otherwise it will become kinked and will not re-expand. The bottle interior is sterilised by filling with a 1 in 20 solution of carbolic and there has been no sepsis attributable to the use of this method. Two sizes of bottle (4 oz. and 10 oz.) have been used, the smaller size being suitable for most cases. Experiment has shown that both sizes of bottle can draw up a column of water 4 mm. in diameter to a height of 100 cm. After repeated use the polyethylene tends to harden and the suction power is reduced. This negative pressure has not given rise to any complications in practice and compares favourably with the use of many electric pumps which may go
building up an ever-increasing negative pressure. Moreover, they effectively immobilise the patient and may cause considerable annoyance if the pump is noisy. The polyethylene bottles, on the other hand, are eminently portable and silent. Despite the limited calibre of the catheter and dispenser spout, there has been no tendency to blockage. We are at present experimenting with nozzle fittings of different shape The screw-on top is being retained, however, and size. because of the access it allows for cleaning. on
I
am
to Mr. J. Hutchison for much helpful criticism and Mr. P. S. Waldie, A.R.P.S. for the diagram.
grateful
advice, and
to
Stobhill General
Hospital, Glasgow.
F. T. CROSSLING.
selected.
It was installed in 1948 and consists of suction points, in three operating-theatres, a reservoir tank, and a pump in the basement with a discharge pipe to a basement yard. The vacuum is maintained between 15 and 25 in. of mercury. Through the cooperation of the Royal Marsden Hospital and British Oxygen Gases Ltd., the following investigations were carried out:
(1) Three sections of pipe were cut out-near a suction point, in the main vacuum line from the theatre floor, and just before the tank. The inside of each pipe was found to be dry and macroscopically clean. Swabs were taken from these three sites and from the inside of the tank. Direct plating produced no growth, and enrichment in broth grew Staphylococcus albus and diphtheroids from two swabs only. (2)
The effluent air was sampled by passing it through a plug of sterile alginate wool of approximately 1 cm. diameter which was then dissolved in a 1%sodium hexametaphosphate solution containing 10% horse serum. The resulting solution was cultured. Two tests were made on different days in which 150 and 200 litres of air (as measured by a gas meter) respectively were pumped. On the first occasion the vacuum was broken at the entrance to the tank; no organisms were recovered. On the second occasion the vacuum was broken at a suction point in a theatre so that air was drawn through most of the system. Staph. albus was isolated, on enrichment only. Quantitative control tests using Staph. aureus showed that the solvent used was not significantly inhibitoiy. 1. New
Engl. J. Med. 1959, 260,
675.