- Email: [email protected]
Modern Technique in Treatment.
THE TREATMENT OF
in Modernof Special Technique A.rticles,
Treatment.
contributed by invitation, 4 Series the Treatment of 11fedical and Surgical Conditions.
on
CCLIV.-THE TREATMENT OF PHLEBITIS. PHLEBITIS occurs in two forms, (1) the plastic, and (2) the suppurative. In the plastic form of phlebitis inflammatory changes occur in the endothelium of the veins and as a result a clot or thrombus appears within the vein. Organisation of this clot by fibrous tissue may occur, the vein being transformed into a In other cases the clot becomes fibrous cord. softened and broken down and the circulation of blood through the vein is resumed. During this process a portion of the clot may become detached and pass to the lungs, resulting in pulmonary embolism. In the suppurative form the vein and the clot which it contains become invaded by pyogenic organisms ; leucocytes enter the clot and cause it to break down into a purulent fluid.
PHLEBITIS.
1307
utmost gentleness in manipulating the abdominal wall during operations. I am strongly against the modern habit of trying to remove an adherent appendix through the same abdominal wound that has been used for inspection or operative procedures in the upper abdomen. A great deal of stretching and pulling of the parietes occurs and it is far better to make a second incision over the appendix, if its removal is required after an operation on the upper abdomen. It is also clear that after abdominal operations the patients should be encouraged to move the legs as soon as possible so as to prevent stagnation of the circulation. W. A. Lister2 has shown that the commonest source from which massive emboli arise is in the iliac veins and their larger tributaries, and he suggests as a preventive measure that movements of the abdominal wall should be encouraged after operation as soon as possible. He also suggests that massage to the lower limbs and breathing exercises should be undertaken as soon as possible after an operation on the abdomen. Another factor which may be of some importance in producing stasis in the femoral vein is the acute flexion at the groin which is produced by placing a bolster beneath the knees in order to prevent the patient slipping down in bed. The use of this support should be
aetiology of Plastic Phlebitis. phlebitis .may be a result of (1) infective fevers, especially typhoid fever, (2) gout, (3) post- condemned. it is advisable to begin, on the After operative thrombo-phlebitis, (4) puerperal phlebitis or third or operation fourth day, to give a mixture containing alba but or dolens, (5) trauma, usually phlegmasia potassium citrate and ammonia three times a day not always, in cases when the veins are varicose. as a prophylactic against clotting. Preventive Treatment of Plastic Phlebitis. Prophylaxis against puerperal phlebitis is similar In the infectious fevers, especially typhoid fever, to that already described against venous clotting operation. The influence of puerperal sepsis phlebitis of the lower limbs is not uncommon. after The diet recommended in typhoid fever was in this connexion is, however, very important. Trauma is a cause of phlebitis usually, but not at one time confined to milk and this substance contains a considerable amount of calcium salts always in cases where the veins in the lower limbs 1 g. per litre : R. Hutchison). It is probable that are varicose. in a long illness the coagulability of the blood will be Treatment of Varicose 17 eins. increased on an exclusively milk diet and as a prophyThe treatment of varicose veins may be summarised lactic measure in typhoid fever other liquids, such as as follows :beef-tea and lemon-water, should be given to avoid (a) Support.-The use of crepe velpeau and indiaa diet solely composed of milk. rubber bandages and elastic stockings has been In gout, where the phlebitis is often multiple and condemned on insufficient grounds. They certainly sometimes symmetrical, the diet should be regulated help to protect the veins from trauma and prevent and appropriate medical treatment, such as colchicine, their over-distension, and in many cases this is the atophan, and Contrexéville water should be prescribed. only treatment necessary. In post-operative thrombo-phlebitis we have a con(b) Spa Treatment.-A great many cases of varicose edition which needs the urgent consideration of both veins have been greatly benefited by treatment at physicians and surgeons. There is an alarming increase Bagnoles de l’Orne in France. In my experience the of pulmonary embolism and many deaths result greatest benefit from the hot springs of the spa has from it after laparotomy. The work of J. G. Clark,1 been in cases where thrombosis has already taken who has brought forward many convincing arguments place in the veins and more or less oedema of the to support his thesis, should be better known. He lower limb has resulted. concludes that post-operative thrombo-phlebitis (c) Surgical.-Removal of localised bunches of results from trauma to the deep epigastric vein varicose veins may be undertaken by surgical excision. during manipulation of the abdominal wall at opera- In many cases where the valves of the veins have tions. He has shown that the clot spreads to the become incompetent and there is great distension deep epigastric vein on the opposite side and to the of the veins when the patient stands erect, Trendeleniliac vein. The long interval, 8-15 days, which inter- burg’s operation of ligature of the saphenous vein venes between the operation and the appearance of in the groin has been used successfully. the thrombosis in the femoral and iliac veins suggests 1919 Sicard3 proposed to inject (d) Injection.-In a slow process with gradual extension of the clot into fluids into the varicose veins with a view of producing the femoral vein from a focus some distance away. a sclerosing thrombosis. Five c.cm. of a solution of The absence of much fever and the fact that the 20 per cent. sodium salicylate are injected into the pulse is slightly, if at all, raised in rate suggests vein, which becomes hard and a firm clot is produced, a traumatic lesion of the vein rather than an infective which eventually leads to shrinking and disappearone. In one case, after a patient had been operated ance of the varix. Apparently embolism does not upon and had developed a typical thrombo-phlebitis occur as the result of this method of treatment. with oedema of the right leg, it became necessary to (e) Treatment when Phlebitis and Thrombosis has perform a second laparotomy. At this second opera- Occurred.-Rest in bed is essential. The limb should tion, two months later, both the epigastric veins be slightly elevated to favour return of the venous were found to be tense, hard, and as large as goose circulation. The inflamed vein may be gently painted quills, while the right one was found to be decidedly with liniment of iodine and then covered with warm The block cotton-wool. varicose and to contain phleboliths. If the whole leg is swollen it should in the iliac vein may or may not be complete; be entirely encased in warm wool and covered with if it is complete we get a swollen cedematous thin mackintosh. If the pain is severe, the skin over leg, whilst if it is incomplete, pulmonary infarc- the painful area may be smeared with a cream made tion may occur without swelling of the lower limb. with green extract of belladonna with twice its weight It is clear from this that should use the Plastic
surgeons
1 Univ. of Penna. Med. Bull.,
1902,
xv., 154.
3
2 THE LANCET, 1927, i., 111. Presse Médicale, June 2nd, 1926.
PUBLIC HEALTH SERVICES.
1308 of
Massage and friction must not be at least three weeks. To prevent further clotting, citrate of potash and ammonia should be given, as in the following glycerine. employed for
phlebitis of the iliac of puerperal infection
prescription
Treatment of Suppurative Phlebitis. The infective focus must be drained or removed(a) e.g., the mastoid process must be drained or the
:-
veins may follow certain cases or uterine and bladder diseases.
appendix removed. (b) Whenever possible
a ligature must be placed on the vein between the affected area and the hearte.g., the jugular vein must be ligatured at the root of the neck in cases of lateral sinus thrombosis. in water four hours. A every tablespoonful Sig. (c) When this has been done, the inflamed vein. After three weeks, if the leg remains swollen, should be thoroughly laid open, the septic clot gentle friction to the skin may be employed but deep removed, and the cavity thoroughly cleansed and . massage is contraindicated. drained whenever anatomical conditions allow of this being done. Pulmonary Embolism. After these essential surgical procedures have been The symptoms of pulmonary embolism appear in carried out, the patient’s strength must be maintained most cases with dramatic suddenness. Some 10 to 14 careful feeding; alcohol and other stimulants days after an operation or after parturition the by should be given when needed, while antistreptococcal is violent seized with in the suddenly patient pain chest. The breathing becomes very difficult and the serum may be given to combat the toxemia. distress of the patient is very great. If the clot is THEODORE THOMPSON, M.D. Camb., B.Sc., large enough to block the pulmonary artery or one F.R.C.P. Lond., F.R.C.S. Eng., of its larger branches, the patient may die in a few Physician to the London Hospital. minutes. If, however, the colt is not so large, the patient recovers and within the next 24 hours a pleural rub may be heard and the patient will bring Within up a quantity of dark-coloured blood. two or three days a dull area may be found at the base of one of the lungs and tubular breathing and increased vocal resonance may be elicited over this area. Indications that pulmonary embolism may REPORTS OF MEDICAL OFFICERS OF HEALTH. occur after an operation are slight. After the postTHE following are some of the 1926 statistics of four to normal on has settled down operative pyrexia and one Scottish county :of the third or fourth day, the temperature, instead remaining quite normal, may show slight signs of oscillation, rising to 99’or 100°F. without any obvious cause. There is usually no pain in the lower limbs, but just before the embolus takes place there may be a little oedema of one or both feet. The prevention of pulmonary embolism is that of thrombosis in the iliac veins. Once thrombosis has taken place the patient must be kept absolutely still and any respiratory exercises and movements of the abdomen and legs must be immediately stopped. Should a clot in a varicose vein show signs of ascending the leg the inflamed vein should be removed and the saphenous vein tied in the groin. It is clear, however, that operative measures on a clot in the iliac vein must be of doubtful value, though in some cases they have been undertaken. When the patient is seized by the crisis of pulmonary embolism, the violent spasm and acute pain are best relieved by a small dose of morphia. In many cases oedema of the lung supervenes and the chest becomes full of bubbling rales. When this occurs one-fiftieth of a grain of atropine should be injected. If there is much cyanosis, oxygen inhalations may be tried, and if * The figures refer to the county landward—i.e., excluding the pulse becomes feeble strychnine, digitalis, and the burghs. camphor should be injected. When once a pulmonary Lancashire. embolus has occurred it is obvious that another Dr. J. J. Butterworth reports that the death-rate portion of clot may become detached and a second attack may follow, and I have seen cases where from cancer has steadily increased from 0-54 per 1000 three or four small emboli have passed into the lungs in 1900 to 1-29 in 1926. During the last ten years during the course of two or three weeks and yet the the percentage of male deaths has gradually increased patient has recovered. In view of this, it is essential from 42-5 to 47-1. Congenital conditions accounted that the patient should be kept absolutely quiet for 41 per cent. of the infant deaths and respiratory in bed for a period of four to six weeks until it may diseases for over 24 per cent. Operative treatment be hoped that the thrombosis in the iliac vein has for tonsils and adenoids is not undertaken at the school clinics but only in hospitals by expert surgeons. become fully organised. During 1926 725 children received such operative aetiology of Suppurative Phlebitis. treatment under the county scheme. The treatment The pyogenic organisms reach the veins from a of defects of vision is undertaken in the eye departfocus of suppuration around them. The most ments of hospitals or by part-time specialists in the are the result of (a) mastoid county clinics. During the year 3343 children were common varieties disease, resulting in septic phlebitis of the lateral treated under the county scheme. The dental staff sinus and internal jugular vein ; (b) facial carbuncle consists of nine whole-time surgeons and one partor boil resulting in infection of the angular vein and time, each assisted by a nurse or dental attendant. There are 18 clinics which serve about 33,000 children. cavernous sinus ; (c) septic conditions in the abdomen, such as appendicitis, gastric ulcer, and tuberculous Owing to the large number requiring treatment, the glands resulting in portal pylephlebitis ; (d) septic dentists concentrate on the younger groups of children
Services. Public Health
English
I
in Modernof Special Technique A.rticles,
Treatment.
contributed by invitation, 4 Series the Treatment of 11fedical and Surgical Conditions.
on
CCLIV.-THE TREATMENT OF PHLEBITIS. PHLEBITIS occurs in two forms, (1) the plastic, and (2) the suppurative. In the plastic form of phlebitis inflammatory changes occur in the endothelium of the veins and as a result a clot or thrombus appears within the vein. Organisation of this clot by fibrous tissue may occur, the vein being transformed into a In other cases the clot becomes fibrous cord. softened and broken down and the circulation of blood through the vein is resumed. During this process a portion of the clot may become detached and pass to the lungs, resulting in pulmonary embolism. In the suppurative form the vein and the clot which it contains become invaded by pyogenic organisms ; leucocytes enter the clot and cause it to break down into a purulent fluid.
PHLEBITIS.
1307
utmost gentleness in manipulating the abdominal wall during operations. I am strongly against the modern habit of trying to remove an adherent appendix through the same abdominal wound that has been used for inspection or operative procedures in the upper abdomen. A great deal of stretching and pulling of the parietes occurs and it is far better to make a second incision over the appendix, if its removal is required after an operation on the upper abdomen. It is also clear that after abdominal operations the patients should be encouraged to move the legs as soon as possible so as to prevent stagnation of the circulation. W. A. Lister2 has shown that the commonest source from which massive emboli arise is in the iliac veins and their larger tributaries, and he suggests as a preventive measure that movements of the abdominal wall should be encouraged after operation as soon as possible. He also suggests that massage to the lower limbs and breathing exercises should be undertaken as soon as possible after an operation on the abdomen. Another factor which may be of some importance in producing stasis in the femoral vein is the acute flexion at the groin which is produced by placing a bolster beneath the knees in order to prevent the patient slipping down in bed. The use of this support should be
aetiology of Plastic Phlebitis. phlebitis .may be a result of (1) infective fevers, especially typhoid fever, (2) gout, (3) post- condemned. it is advisable to begin, on the After operative thrombo-phlebitis, (4) puerperal phlebitis or third or operation fourth day, to give a mixture containing alba but or dolens, (5) trauma, usually phlegmasia potassium citrate and ammonia three times a day not always, in cases when the veins are varicose. as a prophylactic against clotting. Preventive Treatment of Plastic Phlebitis. Prophylaxis against puerperal phlebitis is similar In the infectious fevers, especially typhoid fever, to that already described against venous clotting operation. The influence of puerperal sepsis phlebitis of the lower limbs is not uncommon. after The diet recommended in typhoid fever was in this connexion is, however, very important. Trauma is a cause of phlebitis usually, but not at one time confined to milk and this substance contains a considerable amount of calcium salts always in cases where the veins in the lower limbs 1 g. per litre : R. Hutchison). It is probable that are varicose. in a long illness the coagulability of the blood will be Treatment of Varicose 17 eins. increased on an exclusively milk diet and as a prophyThe treatment of varicose veins may be summarised lactic measure in typhoid fever other liquids, such as as follows :beef-tea and lemon-water, should be given to avoid (a) Support.-The use of crepe velpeau and indiaa diet solely composed of milk. rubber bandages and elastic stockings has been In gout, where the phlebitis is often multiple and condemned on insufficient grounds. They certainly sometimes symmetrical, the diet should be regulated help to protect the veins from trauma and prevent and appropriate medical treatment, such as colchicine, their over-distension, and in many cases this is the atophan, and Contrexéville water should be prescribed. only treatment necessary. In post-operative thrombo-phlebitis we have a con(b) Spa Treatment.-A great many cases of varicose edition which needs the urgent consideration of both veins have been greatly benefited by treatment at physicians and surgeons. There is an alarming increase Bagnoles de l’Orne in France. In my experience the of pulmonary embolism and many deaths result greatest benefit from the hot springs of the spa has from it after laparotomy. The work of J. G. Clark,1 been in cases where thrombosis has already taken who has brought forward many convincing arguments place in the veins and more or less oedema of the to support his thesis, should be better known. He lower limb has resulted. concludes that post-operative thrombo-phlebitis (c) Surgical.-Removal of localised bunches of results from trauma to the deep epigastric vein varicose veins may be undertaken by surgical excision. during manipulation of the abdominal wall at opera- In many cases where the valves of the veins have tions. He has shown that the clot spreads to the become incompetent and there is great distension deep epigastric vein on the opposite side and to the of the veins when the patient stands erect, Trendeleniliac vein. The long interval, 8-15 days, which inter- burg’s operation of ligature of the saphenous vein venes between the operation and the appearance of in the groin has been used successfully. the thrombosis in the femoral and iliac veins suggests 1919 Sicard3 proposed to inject (d) Injection.-In a slow process with gradual extension of the clot into fluids into the varicose veins with a view of producing the femoral vein from a focus some distance away. a sclerosing thrombosis. Five c.cm. of a solution of The absence of much fever and the fact that the 20 per cent. sodium salicylate are injected into the pulse is slightly, if at all, raised in rate suggests vein, which becomes hard and a firm clot is produced, a traumatic lesion of the vein rather than an infective which eventually leads to shrinking and disappearone. In one case, after a patient had been operated ance of the varix. Apparently embolism does not upon and had developed a typical thrombo-phlebitis occur as the result of this method of treatment. with oedema of the right leg, it became necessary to (e) Treatment when Phlebitis and Thrombosis has perform a second laparotomy. At this second opera- Occurred.-Rest in bed is essential. The limb should tion, two months later, both the epigastric veins be slightly elevated to favour return of the venous were found to be tense, hard, and as large as goose circulation. The inflamed vein may be gently painted quills, while the right one was found to be decidedly with liniment of iodine and then covered with warm The block cotton-wool. varicose and to contain phleboliths. If the whole leg is swollen it should in the iliac vein may or may not be complete; be entirely encased in warm wool and covered with if it is complete we get a swollen cedematous thin mackintosh. If the pain is severe, the skin over leg, whilst if it is incomplete, pulmonary infarc- the painful area may be smeared with a cream made tion may occur without swelling of the lower limb. with green extract of belladonna with twice its weight It is clear from this that should use the Plastic
surgeons
1 Univ. of Penna. Med. Bull.,
1902,
xv., 154.
3
2 THE LANCET, 1927, i., 111. Presse Médicale, June 2nd, 1926.
PUBLIC HEALTH SERVICES.
1308 of
Massage and friction must not be at least three weeks. To prevent further clotting, citrate of potash and ammonia should be given, as in the following glycerine. employed for
phlebitis of the iliac of puerperal infection
prescription
Treatment of Suppurative Phlebitis. The infective focus must be drained or removed(a) e.g., the mastoid process must be drained or the
:-
veins may follow certain cases or uterine and bladder diseases.
appendix removed. (b) Whenever possible
a ligature must be placed on the vein between the affected area and the hearte.g., the jugular vein must be ligatured at the root of the neck in cases of lateral sinus thrombosis. in water four hours. A every tablespoonful Sig. (c) When this has been done, the inflamed vein. After three weeks, if the leg remains swollen, should be thoroughly laid open, the septic clot gentle friction to the skin may be employed but deep removed, and the cavity thoroughly cleansed and . massage is contraindicated. drained whenever anatomical conditions allow of this being done. Pulmonary Embolism. After these essential surgical procedures have been The symptoms of pulmonary embolism appear in carried out, the patient’s strength must be maintained most cases with dramatic suddenness. Some 10 to 14 careful feeding; alcohol and other stimulants days after an operation or after parturition the by should be given when needed, while antistreptococcal is violent seized with in the suddenly patient pain chest. The breathing becomes very difficult and the serum may be given to combat the toxemia. distress of the patient is very great. If the clot is THEODORE THOMPSON, M.D. Camb., B.Sc., large enough to block the pulmonary artery or one F.R.C.P. Lond., F.R.C.S. Eng., of its larger branches, the patient may die in a few Physician to the London Hospital. minutes. If, however, the colt is not so large, the patient recovers and within the next 24 hours a pleural rub may be heard and the patient will bring Within up a quantity of dark-coloured blood. two or three days a dull area may be found at the base of one of the lungs and tubular breathing and increased vocal resonance may be elicited over this area. Indications that pulmonary embolism may REPORTS OF MEDICAL OFFICERS OF HEALTH. occur after an operation are slight. After the postTHE following are some of the 1926 statistics of four to normal on has settled down operative pyrexia and one Scottish county :of the third or fourth day, the temperature, instead remaining quite normal, may show slight signs of oscillation, rising to 99’or 100°F. without any obvious cause. There is usually no pain in the lower limbs, but just before the embolus takes place there may be a little oedema of one or both feet. The prevention of pulmonary embolism is that of thrombosis in the iliac veins. Once thrombosis has taken place the patient must be kept absolutely still and any respiratory exercises and movements of the abdomen and legs must be immediately stopped. Should a clot in a varicose vein show signs of ascending the leg the inflamed vein should be removed and the saphenous vein tied in the groin. It is clear, however, that operative measures on a clot in the iliac vein must be of doubtful value, though in some cases they have been undertaken. When the patient is seized by the crisis of pulmonary embolism, the violent spasm and acute pain are best relieved by a small dose of morphia. In many cases oedema of the lung supervenes and the chest becomes full of bubbling rales. When this occurs one-fiftieth of a grain of atropine should be injected. If there is much cyanosis, oxygen inhalations may be tried, and if * The figures refer to the county landward—i.e., excluding the pulse becomes feeble strychnine, digitalis, and the burghs. camphor should be injected. When once a pulmonary Lancashire. embolus has occurred it is obvious that another Dr. J. J. Butterworth reports that the death-rate portion of clot may become detached and a second attack may follow, and I have seen cases where from cancer has steadily increased from 0-54 per 1000 three or four small emboli have passed into the lungs in 1900 to 1-29 in 1926. During the last ten years during the course of two or three weeks and yet the the percentage of male deaths has gradually increased patient has recovered. In view of this, it is essential from 42-5 to 47-1. Congenital conditions accounted that the patient should be kept absolutely quiet for 41 per cent. of the infant deaths and respiratory in bed for a period of four to six weeks until it may diseases for over 24 per cent. Operative treatment be hoped that the thrombosis in the iliac vein has for tonsils and adenoids is not undertaken at the school clinics but only in hospitals by expert surgeons. become fully organised. During 1926 725 children received such operative aetiology of Suppurative Phlebitis. treatment under the county scheme. The treatment The pyogenic organisms reach the veins from a of defects of vision is undertaken in the eye departfocus of suppuration around them. The most ments of hospitals or by part-time specialists in the are the result of (a) mastoid county clinics. During the year 3343 children were common varieties disease, resulting in septic phlebitis of the lateral treated under the county scheme. The dental staff sinus and internal jugular vein ; (b) facial carbuncle consists of nine whole-time surgeons and one partor boil resulting in infection of the angular vein and time, each assisted by a nurse or dental attendant. There are 18 clinics which serve about 33,000 children. cavernous sinus ; (c) septic conditions in the abdomen, such as appendicitis, gastric ulcer, and tuberculous Owing to the large number requiring treatment, the glands resulting in portal pylephlebitis ; (d) septic dentists concentrate on the younger groups of children
Services. Public Health
English
I