589 sooner healed than another is started. Where the skin is constantly eczematous, or the transudation such as to keep the leg greatly swollen; to this class of sufferers we can give complete and permanent relief, through the radical operation. Heretofore we have been limited to one of three procedures, acupressure, ligature, and excision. 1 Acupressure is performed by passing two needles through the skin. underneath the vein about one inch apart, silk is twisted in a figure-of-eight suture over the ends sufficiently firm to constrict completely the vein, the underlying skin is protected with little plegits of gauze. If thought best the vein can be divided with a tenotome subcutaneously between the needles. This method is not very generally countenanced in this day and age of progressive surgery, the danger of infection is great and the element of uncertainty makes it unpopular. There is danger of transfixing the vein also. Of the various methods advocated for the radical cure this is most frequently followed by failure. The ligature has been used from a very remote surgical period. Paulus Aegineta who practiced surgery somewhere between the fourth and seventh century, made use of this method. This was many centuries before Ambrosi Paré advocated the ligature for the control of hemorrhage, many of the older surgeons tied the veins in two places and divided between the ligatures. Dupuytren tied and cut above the ligatures. After selecting the main trunk or one or more of the principal tributaries the vessel is exposed. An aneurysm needle armed with a silk ligature is passed beneath the vein and tied, or the ligature is passed double, the loop cut and separated as in the former operation; then tied and the vein cut between, after which the wound is closed and sealed. A few years ago Trendelenburg recommended ligation and division of the great saphena vein in this affection. He attributed the defect to the insufficiency of the valves, and that the very great pressure existing in the varices is removed by occlusion of the saphena and the circulation is in no way impaired; he found that ulcers of the leg healed very promptly and the patients made a rapid recovery. Excision is a very ancient operation and has given far by the best results. It was practiced by Celsus in veins that were not very tortuous, but fell into disuse owing to the disastrous results due to infection. Lisfranc tried to popularize the operation by slightly modifying it, but failed owing to the frequency of death due to septic influence. Since the days of modern surgery this operation is the one most frequently resorted to and with most gratifying results, the wound unites primarily and the danger from sepsis. is nil. The operation is performed by making a longitudinal incision over the long saphena above the knee, exposing the vein and isolating it from the surrounding tissues and passing two ligatures two or more inches apart, after tying. The intervening part of the vein is excised, and the wound closed without drainage, The after treatment consists of rest in bed, elevation of the leg and the application of a bandage daily; this operation is followed not infrequently by failure. I feel that I must mention only to discourage the use of some of many unsurgical means that have been brought forward from time to time. At 590 one time the veins were crushed, thereby hoping to obliterate the main channel; at another time corroding acids were made use of for the same purpose. Injections into the veins have been used and followed by disastrous results. All of these measures are unsurgical and should not be entertained. During my stay in Hamburg during the past summer, I had the pleasure of observing Dr. Sick and his assistants do what seemed to me the ideal operation for this pathological condition, and the result up to the present time seems to justify its further trial. The operation was suggested by Dr. Schede and first carried out by him and his assistants. Some of these cases have been under observation for two years and, I am informed by these gentlemen, in not a single instance, has the operation been otherwise than satisfactory. The patient is carefully prepared the day before by a general bath. The bowels are thoroughly emptied. The limb to be operated on is carefully scrubbed and shaved, dressed with a 5 per cent carbolic acid, moist dressing. The patient is anesthetized, the limb elevated a sufficient length of time and a rubber constrictor applied. The rubber band, however, is not the invariable rule. The limb is encircled by an incision, commencing usually below the knee some three or four inches. The same incision may be made above the knee if it is thought unnecessary to divide the external saphenous. The incision cuts through the skin and cellular tissue down to the muscular layer, dividing everything, as the veins are cut they are picked up with haemostatic forceps, for the two-fold purpose of preventing unnecessary loss of blood and guard against the greater danger of air emboli. In many instances the veins can be picked up and cut between two pair of forceps. After the completion of this incision, every bleeding point is ligated with sterilized catgut, especial care is given to this part of the operation. The wound is then closed by carefully approximating the skin and fascia, first by deep retention sutures some six, eight or more, whatever seems necessary to relieve the tension on the approximate sutures. The wound is then cleaned and dried of all fluid that can act as a culture media, and dressed in the most thorough aseptic manner, a roller is snugly applied, the patient placed in bed, and the leg elevated. Frequently you will find, after making the above described operation, that there are many knotty and enlarged veins about the knee. To prevent trouble from this source, Dr. Schede is in the habit of making an excision of the long saphenous in the upper part of the thigh, much after the manner of Trendelenburg's primary operation. He cuts down upon the vein and removes about three inches and then closes this wound without drainage. If the wound remains free from infection there is no need of disturbing the dressing for ten days. They are then removed, the stitches taken out and the dressings reapplied with the same care. About three weeks is required to keep these patients in bed, when they are allowed to get up and go about their usual vocations. The result of this operation thus far is very satisfactory and bids fair to supplant all others in vogue at the present time. 591 Chronic Atrophic Rhinitis. BY LEON ROSENWALD, M. D., Professor of Histology and Microscopy in the University Medical College; Professor of Pathology in the READ BEFORE THE TWIN CITY MEDICAL ASSOCIATION. the student of pathology chronic atrophic rhinitis presents no deep fibrous change, and contraction. That this process can start without any very marked symptoms of inflammation is a well known fact, but the vast majority of cases are not primary, but the results of hypertrophic inflammations which have lasted for some years, and it is for this reason that the disease is peculiar to adult life. The glandular structures of the mucus membrane are practically destroyed, with the exception of that lining the upper third of the nose, the ethmoid cells, etc. This must be borne in mind for it explains and elucidates the train of symptoms which characterize this most disagreeable condition of the nose. A feeling of pressure in the frontal region, the formation of scabs or crusts, a peculiar odor, and frequent nose bleedings suffice to make the diagnosis which can be confirmed by the rhinoscopic examination. Patients very frequently complain of dryness in the pharynx, and the practitioner must not be surprised at this, for the moistening function of the nose has been destroyed, and taken up partially by the pharynx. The formation of crusts has to the rhinologist always been a source of much speculation. By some, bacteria are supposed to be the evil genius, but these men see nothing in medicine but micro-organisms. The true cause is mechanical only. As the secretion from the upper part of the nose flows over the middle and inferior turbinated bones the inspired air absorbs what water there is, and leaves the solid matters remaining. The crusts grow by the continual addition of solid matters from the secretion over the primary deposit, and finally form a complete coat of the interior of the nose. It is now that the bacteria which are ubiquitous, find a good culture medium and lodge there to form putrefactive changes. This, I believe, is the only part bacteria play. Climatic conditions very markedly affect this process. The higher the altitude the fewer putrefactive germs are found; and consequently, the stench will be less. We know that atrophic rhinitis is found in very high elevations, but with the absence of that horrible stench which accompanies crust formations in lower altitudes, and especially in countries lying near large bodies of water. This I consider an additional proof that bacteria are only accessories to the crime. |
