Surgery, with Special Reference to Podiatry Part 16

The tissues around a varicose vein become atrophied from pressure, and often a very large vein will be in evidence whose thin walls are in close contact with the skin, and in this condition, rupture and hemorrhage are probable. Varicose veins are apt to inflame and thrombosis frequently occurs.

+Treatment.+ The treatment of varix may be palliative or curative, but whichever is followed, endeavor first to remove the cause.

In palliative treatment, attend to the general health, keep up the force and activity of the circulation, and prevent constipation.

Recommend the patient to exercise in the open air and to lie down, if possible, every afternoon. Locally, in varix of the leg, order a flannel bandage to support the vein and drive the blood into the deeper vessels which have muscular support. (For technic, see chapter on bandaging).

The curative or operative treatment of varicose veins consists of performing a resection of the internal saphenous vein of one or two inches, near the saphenous opening into the femoral. This is known as the _Trendelenburg_ method. About 90 per cent of all cases can be cured by this method. The operation can be performed under local anesthesia and presents no difficulties.

Another procedure is known as _Schede's_ method. This consists of making a circular incision around the leg just below the knee joint, and in tying all the superficial veins thus exposed.

_Mayo's_ operation consists of the total extirpation of the internal saphenous vein from the saphenous opening to the internal malleolus. A small incision is made high up, and at a distance of from 8 to 10 inches, a second incision is made, and in this manner the entire vein is removed by making several incisions.

The patient should remain in bed about three weeks following an operation of this kind and afterwards an elastic stocking, or an ideal bandage, should be worn for a considerable time.

+Phlebitis+, or inflammation of a vein, may be plastic or purulent in nature. Plastic phlebitis, while occasionally due to gout, or to some other const.i.tutional condition, usually arises from a wound or other injury, from the extension to the vein of a perivascular inflammation, or, in the portal region, from an embolus.

Varicose veins are particularly liable to phlebitis. When phlebitis begins, a thrombus forms because of the destruction of the endothelial coat, and this clot may be absorbed or organized.

+Suppurative Phlebitis+ is a suppurative inflammation of the vein, arising by infection from suppurating perivascular tissues (_infective thrombophlebitis_). It is most frequently met with in cellulitis or phlegmonous erysipelas, but there are a great many other causes.

A thrombus forms, the vein wall suppurates, is softened and in part destroyed, and the clot becomes purulent. No bleeding occurs when the vein ruptures, as a barrier of clot keeps back the blood stream. The clot of suppurative phlebitis cannot be absorbed and cannot organize.

Septic phlebitis causes pyemia, and the infected clots of pyemia cause phlebitis. The symptoms of phlebitis are pain, which is at once felt in the limb along the track of the inflamed vein, and tenderness along the same area; the overlying skin is red, hot, and tender, and the lymphatic nodes in the groin swell; there is marked edema, but the inflamed venous cords can be readily felt. The const.i.tutional disturbance is marked; rigors and high temperature, 103F. to 105F.

(remittent type), are followed by profuse sweats. The general condition, facies and anxiety, dry and parched tongue, delirium and general distress, at once directs attention to the infectious nature of the trouble. The leucocyte count will show a marked increase in the number of polynuclears.

+Treatment.+ The treatment of phlebitis may be cla.s.sified into preventive and curative, the latter being subdivided into (_a_), general or symptomatic, and (_b_), local or surgical.

The preventive treatment is summed up in the word asepsis. The influence of asepsis in the management of wounds has completely revolutionized surgical practice, and the old fatal types of pyemia and septicema have now practically vanished.

Septic and pyogenic phlebitis still remain as consequences of accidental wound contaminations and as a penalty for the neglect of surgical cleanliness.

Prophylatic measures, by the use of internal remedies which diminish the coagulability of the blood, such as Wright's citric acid treatment, are recommended for the prevention of thrombosis.

Ant.i.toxins have not proven to be of benefit in this condition.

The curative treatment may be symptomatic, local, const.i.tutional, or surgical. The const.i.tutional treatment is directed to the general cause, if possible, as in the gouty, rheumatic, syphilitic, and chloritic cases; beyond this, there is no specific treatment. The antistreptococcal and staphylococcal sera are usually prescribed in the septic forms, but thus far, more as a forlorn hope than with the expectation of accomplis.h.i.+ng any definite results. The symptomatic treatment, on the other hand, is always indicated to diminish pain, to support and strengthen the circulation, and to favor elimination. The main reliance is to be placed upon the local treatment, combined with good nursing, appropriate food, and moderate stimulation.

The local treatment is summed up in the following indications: (_a_), immobilization and absolute rest of the affected limb; (_b_), elevated position of the foot of the bed or of the limb to favor the drainage of the venous current toward the trunk. The limb should be covered with cotton batting and bandaged, over a gutter-splint of cardboard, extending from the foot to the thigh, to immobilize the knee. In the superficial inflammations, with much redness and heat, an even layer of any of the kaolin mixtures may be applied between thin layers of gauze, like an antiseptic poultice, over the entire extremity, and especially over the inflamed parts. A saturated watery solution of 25 per cent. ichthyol, painted over the entire surface will also prove decidedly beneficial in cases complicated with lymphangitis. Unguentum Crede, mercurial ointment, and the so-called resolvent lotions have been tried, but none of these can compare in their beneficial effect with kaolin poultices, with or without ichthyol, or the liberal application of broad compresses, thoroughly saturated with a weak lead and opium lotion, which latter acts not only as a local astringent, but as a marked sedative. Immobilization and rest should be maintained for a month or more.

+Operative Treatment.+ The operative treatment of acute septic thrombophlebitis has in view three indications, and the procedures adopted must vary according to these: (1) ligation of the vein between the thrombotic focus and the uninfected vein on the cardiac side, in order to obstruct the further advance of the infection, and thus prevent the entrance of septic emboli into the circulation; (2) removal of the primary focus of infection by direct incision into the veins, evacuation of the septic thrombus and drainage; (3) extirpation of the infected veins with the contained clot and septic contents.

CHAPTER XIII

+SPECIAL FORMS OF INFLAMMATION+

+Syphilis+ is a chronic, infectious, and sometimes hereditary, const.i.tutional disease. Its first lesion is an infecting area or chancre, which is followed by lymphatic enlargements; eruptions upon the skin and mucous membranes; affections of the appendages of the skin, (hair and nails); chronic inflammation and infiltration of the cellulo-vascular tissue, bones and periosteum, and later, often by gummata. This disease is caused by a microorganism known as the _spirochaeta pallida_ or _treponema pallidum_ of Schaudinn and Hoffmann.

+Transmission of Syphilis.+ This disease can be transmitted (_a_), by contact with the tissue-elements or virus acquired syphilis, and (_b_), by hereditary transmission, hereditary syphilis.

The poison cannot enter through an intact epidermis or epithelial layer; an abrasion or solution of continuity is requisite for infection.

Syphilis is usually, but not always, a venereal disease. It may be caught by infection of the genitals during coition; by infection of the tongue or lips in kissing; by the use of an infected towel on an abraded surface; by smoking poisoned pipes, and by drinking out of infected vessels.

The initial lesion of syphilis may be found on the finger, p.e.n.i.s, eyelid, lip, tongue, cheek, palate, nipple, etc. Syphilis can be transmitted by vaccination with human lymph which contains the pus of a syphilitic eruption or the blood of a syphilitic person. Syphilis is divided into three stages (1) the primary stage-chancre and indolent bubo; (2) the secondary stage-disease of the upper layer of the skin and mucous membranes, and (3) the tertiary stage-affections of connective tissues, bones, fibrous and serous membranes, and parenchymatous organs.

+Syphilitic Periods.+ (1) period of primary incubation-the time between exposure and the appearance of the chancre, from ten to ninety days, the average time being three weeks; (2) period of primary symptoms-chancre and bubo of adjacent lymph glands; (3) period of secondary incubation-the time between the appearance of the chancre and the advent of secondary symptoms,-about six weeks as a rule; (4) period of secondary symptoms-lasting from one to three years; (5) intermediate period-there may be no symptoms or there may be light symptoms which are less symmetrical and more general than those of the secondary period; it lasts from two to four years, and ends in recovery or tertiary syphilis; and (6) period of tertiary symptoms-indefinite in duration; the fifth and sixth may never occur, the disease being cured.

+Primary Syphilis.+ The primary stage comprises the chancre or infecting sore or bubo. A chancre or initial lesion is an infective granuloma resulting from the poison of syphilis. The chancre appears at the point of inoculation, and is the first lesion of the disease. During the three weeks or more requisite to develop a chancre the poison is continuously entering the system, and when the chancre develops, the system already contains a large amount of poison.

A chancre is not a local lesion from which syphilis springs, but is a local manifestation of an existing const.i.tutional disease, hence excision is entirely useless. The hard chancre, or initial lesion, never appears before the tenth day after exposure, it may not appear for weeks, but it usually arises in about twenty-one days. The lesion commonly appears as a round, indurated, cartilaginous area with an elevated edge, which ulcerates, exposing a velvety surface looking like raw ham; it bleeds easily, rarely suppurates, does not spread, and the discharge is thin and watery.

The bubo of syphilis is multiple, consisting of a chain of glands, freely movable, indurated, painless, small and slow in growth, and the skin over the bubo is normal.

A positive diagnosis of syphilis can be made when an indurated sore is followed by multiple indolent glands or buboes in the groin and by the enlargement of distant glands.

+Secondary Glands.+ The symptoms are noticed from four to six weeks after the stage of the induration of the chancre, and may continue to appear at any time, up to twelve months. The most constant are certain eruptions on the skin, faucial inflammation, and enlargement or induration of the lymphatic glands; others are febrile reaction, pains in the back or limbs, swelling of the joints, iritis and falling out of the hair.

+Tertiary Syphilis.+ These symptoms appear from one to two years after contagion and may continue to break out from ten to fifteen years, or more. The characteristic lesions are certain late eruptions on the skin, periost.i.tis and nodes on the bones, and growths in the subcutaneous tissue, muscle, and viscera, especially the liver and spleen. These growths, in the viscera and other parts, which are so characteristic of syphilis in its later stages, are known as gummata.

They consist of a substance like granulation tissue, with a varying proportion of cells. In early stages they are grayish, gelatinous, and transparent, but the cells undergo fatty change and caseation takes place, so that the centre becomes yellow, and the circ.u.mference develops into fibrous tissue, which contracts like a scar tissue.

Sometimes gummata break down completely, and suppuration, with destruction of the tissues in which they are situated, takes place; thus caries and necrosis not infrequently follow nodes on the bones.

+Treatment.+ Mercury is the drug of great benefit in syphilis. This can be administered either internally, by inunction, or by injection. Of all the preparations to be given internally, protiodide of mercury, in one quarter grain doses, three times a day, is to be preferred.

+Inunction+ represents the most efficient way of administering the mercurial treatment, when the stomach is intolerant of drugs, or when administered by the mouth in full doses, they do not favorably modify the symptoms. The patient is instructed to take a warm bath, and the mercury is then well rubbed in over the inner surface of the forearm and arm and alongside of the chest for fifteen minutes. Either the oleate of mercury, 10 per cent., or the ordinary mercury ointment is commonly employed; the former is more clean, but less efficient. The rubbings should be done by the patient, should be made over a large surface of the body, and should be performed thoroughly; one dram (4.0) of blue ointment is rubbed in daily. For the injections, a 10 per cent. salicylate of mercury in olive oil is to be preferred; 10 to 15 minums of this solution is to be injected into the b.u.t.tocks, three times a week. The dose is gradually to be increased until 30 drops are employed. Recently salvarsan (606) in 0.6, or 10 grain doses is given either intravenously or intraspinally. Neosalvarsan (914) is to be similarly given. The latter has the advantage in that sterile water is used, and that, as a rule, there is no reaction from its injection.

Iodide of pota.s.sium in large doses (60 to 90 grains) three times a day, is also to be given.

+Tuberculosis.+ Tuberculosis is an infectious disease due to the deposition and multiplication of the tubercule bacillus in the tissues of the body. It is characterized either by the formation of tubercules, or by a wide spread infiltration, both of these conditions tending to caseation, sclerosis, or ulceration.

A tubercular lesion may undergo calcification.

A tubercule is an infective granuloma, appearing to the unaided vision as a semitransparent ma.s.s, gray in color, and the size of a mustard seed.

The microscope shows that a tubercule consists of a number of cell cl.u.s.ters, each cl.u.s.ter consisting of one or of several polynucleated giant cells, surrounded by a zone of epitheloid cells which are surrounded by an area of leucocytes. Giant cells, which also form by coalescence of the epithelioid cells, are not always present. The bacillus, when found, exists in the epithelioid cells, and sometimes in the giant cells; it may not be found, having once existed, but having been subsequently destroyed. It is often overlooked.

In an active tubercular lesion, even if the bacillus be not found, injection of the matter into a guinea-pig will produce lesions in which it can be demonstrated.

A tubercule may caseate, a process that is destructive and dangerous to the organism. Caseation forms cheesy ma.s.ses, which may soften into tubercular pus, may calcify, and may become encapsulated by fibroid tissue. Tubercular disease of the bones and joints have already been described in a previous chapter.

+Treatment.+ Destroy the bacilli present and radically remove infected areas which are accessible. Incomplete operations are apt to be followed by diffuse tuberculosis.

Bier's venous or obstructive hyperemia is especially to be recommended in tuberculosis of the ankle joint (for technic, see chapter on Therapeutics).

Plenty of fresh air, good nouris.h.i.+ng food and tonics are indicated as a routine treatment.

+Teta.n.u.s.+ Teta.n.u.s is an infectious disease, invariably preceded by some injury. The wound may have been severe or it may have been so slight as to have attracted no attention.