Terminal care
From Primary Surgery
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34 Miscellaneous
V A S C U L A R S U R G E R Y
Varicose veins
Besides the control of bleeding (Chapter 3) and the repair of injured vessels (Chapter 55), the only other * primary vascular surgery* is that of varicose veins. You will seldom need to operate on them, because, although about 15% of the people in the world have them, few of these are in the developing countries. Firstly a little theory. ANATOMY AND PHYSIOLOGY. The varicose veins in a patient's leg are the result of excessive pressure inside them, usually from failure of their valves. There are four kinds of leg vein, and they all have valves which stop blood flowing downwards away from the heart. (1) The long and short saphenous veins run above the deep fascia, and are usually below the fibrous layer of the superficial fascia. They have numerous valves which direct blood upwards towards the heart. The most important of these is the 'femoral valve', in the long saphenous vein, just before it penetrates the deep fascia to join the femoral vein. The femoral valve prevents blood from the femoral vein flowing back into the saphenous vein. (2) The superficial collecting veins are tributaries of the saphenous veins. They lie between the skin and the fibrous layer of the superficial fascia. They have valves, but they are poorly supported by the tissue around them, and easily dilate and become varicose. (3) The deep veins accompany the arteries, and run among the muscles deep inside the leg. When the contractions of the muscles squeeze them, their valves direct the squeezed blood towards the heart. (4) Several perforating veins go through the deep fascia, to join the superficial collecting veins to the deep veins. Their valves direct blood into the leg. The most important of these perforating veins are just behind the medial border of the tibia. When a patient stands at rest, the superficial veins on the dorsum of his foot support a column of blood that reaches to his right heart. While his leg muscles are relaxed, this blood flows through his perforating veins, into the deep veins inside his leg. When he walks, the contractions of his leg muscles squeeze the blood from his deep veins up towards his heart. This cycle of contraction and relaxation reduces the pressure in his superficial veins, and in a normal person prevents varicosities. However, if the valves of his deep perforating veins are incompetent, blood from inside his leg can squirt out at high pressure, into his unsupported superficial collecting veins. This distends them, and makes them varicose. It also alters the surrounding tissue, so that it is liable to ulcerate. If the valves which guard his long and short saphenous veins are incompetent, the blood in his femoral and popliteal veins can flow downwards, into his saphenous veins, and make them varicose. The aim of surgery is to stop blood flowing backwards through veins with incompetent valves. A few varicose veins are the result of obstruction, but most are due to failure of the valves of the musculovenous pumps that return blood from the leg. This Valve failure* takes two forms: (1) In primary varicose veins the valves of a patient's saphenous system fail, while the deep veins of his legs remain normal; his symptoms are usually mild, and his legs rarely ulcerate. (2) In secondary or post-thrombotic varicose veins, his deep veins, or the communicating veins between his superficial and deep systems, have had their valves destroyed by thrombosis. Ulceration is more common, and treatment more difficult. Both kinds of varicose veins are associated with Western life-styles, but it is not known why. Varicose veins are unsightly; they cause aching and cramps, a scaly, itchy, varicose eczema, swelling of the legs, and ulceration; occasionally they bleed. A patient's symptoms may bear little relationship to the size and extent of his varicose veins. If they are primary, the swelling usually only involves his feet and ankles, and resolves completely overnight. If they are secondary, his lower legs may be swollen all the time. If he has primary varicose veins, there are several things you can do, either alone, or more often in combination: (1) You can inject a little irritant solution into 2 cm of a vein (sclerotherapy), so as to inflame its walls, and make it shed its endothelium. If you then keep the vein empty, by compressing its inflamed walls together for 6 weeks without interruption, they will stick together and not recanalize. (2) If he has varicosities in his long saphenous system, you can tie his long saphenous vein flush with his femoral vein, and at the same time tie: (a) the tributaries that enter it nearby, and (b) any incompetent connections it has with the deep system. (3) If he has varicosities of his short saphenous system, you can tie his short saphenous vein at his saphenopopliteal junction. (4) You can pass a stripper through his long and short saphenous veins, pull them out completely, and so disconnect the varicosities in his superficial collecting veins from the high pressure in his saphenous veins. (5) You can remove some varices when indicated. If he has posthrombotic (secondary) varicose veins, it may be possible to cure him by tying every incompetent perforating vein; but these are difficult to find and tie, so we don't tell you how to do it here. The surgery that you are prepared to do on a particular patient will depend on your circumstances, and his. Any form of treatment is of limited value, if his deep and his perforating veins, his skin, and his subcutaneous tissues, have already been severely damaged. Sclerotherapy needs careful attention to detail, but it can be very effective, and has few dangers. The main danger of surgery is that, if you tie his superficial veins when the valves of his deep ones are incompetent, you may make him worse. · STRIPPER, for varicose veins, Nabatoff, in sterilizer case, complete with 3 metal olives, cable and handle, one only. Optional. This is the complete outfit. B E S U R E T H A T T H E V A L V E S O F HIS D E E P V E I N S A R E C O M P E T E N T B E F O R E Y O U T I E HIS S U P E R F I C I A L V E I N S VARICOSE VEINS EXAMINATION. Examine the patient standing in a good light. Feel his veins. If he is obese, percuss the course of his saphenous veins. Examine his peripheral pulses. if there is ulceration, brawny induration, and marked hyperpigmentation, the valves of his deep veins are almost certain- ly incompetent, and his varicose veins are secondary. Otherwise they are probably primary. To test the competence of his perforating veins and the valves of his greater saphenous system, lay him down, raise his leg, and massage his veins proximally to empty them. On his upper thigh apply a rubber tube tourniquet, tight enough to compress his veins. Stand him up and ask him to move his forefoot up and down, so as to actuate his calf muscle pump. Inspect his varices for 30 seconds, and then remove the tourniquet. If his veins gradually fill from below as he stands, and continue to fill gradually from below when the tourniquet is released, the valves in the veins of his legs are normal. If his veins fill rapidly from below, his varices are being filled from his deep veins, and the valves of his perforating veins are incompetent. if blood flows rapidly into his greater saphenous vein from above after removing the tourniquet, his femoral valve is incompetent. To test the competence of the valves of his short saphenous vein, apply two tourniquets, one above his knee to occlude his long saphenous vein and another just below his popliteal fossa. Stand him up, leave the long saphenous tourniquet on, and remove the tourniquet obstructing his short saphenous vein. Observe how his short saphenous system fills. To find the sites of major incompetent perforating veins: (1) Look for visible and palpable 'blowouts' of subcutaneous veins. (2) Repeat the tourniquet test at lower levels, and occlude the vein just distal to each blowout. (3) Feei for circular gaps in his deep fascia in the anatomical sites where you expect to find them. DIAGNOSIS. Here we are only concerned with the common causes of varicose veins. Any causes of inguinal or retroperitoneal compression that might produce varicose veins are usually obvious. If there is a thrill or bruit (rare), he has an arteriovenous fistula. Suggesting primary varicose veins--usually start at an early age (15 to 25). No incompetence of the perforators shown by the test above. Incompetence demonstrated by back-flow on release of the upper thigh tourniquet (long saphenous), or just below his popliteal fossa (short saphenous). Suggesting post-thrombotic varicose veins--a history of venous thrombosis (unusual), an older age, less obvious veins partly hidden by eczema, fat necrosis, or ulceration. His long saphenous vein may be dilated. NON-OPERATIVE T R E A T M E N T INDICATIONS. (1) Minor symptoms. CONTRAINDICATIONS. These are also the indications for surgery. (1) Large varicosities. (2) Symptoms, such as aching of sufficient intensity to merit sclerotherapy or surgery. METHOD. Aim to improve his general health and to reduce his symptoms. Encourage him to lose weight (he is usually overweight), to walk, to avoid prolonged standing and sitting, and to raise his leg frequently. If possible, have him fitted with elastic stockings from his distal metatarsals to just below his knee. CAUTION ! If he uses elastic bandages, make sure that they do not have a tourniquet effect. S C L E R O T H E R A P Y INDICATIONS. (1) The cosmetic treatment of small primary varicose veins. (2) Incompetent perforating veins without an incompetent femoral valve. (3) Varicose veins which persist or recur after surgery. CONTRAINDICATIONS. (1) An incompetent femoral valve. (2) Varicosities at or above the knee. (3) Gross obesity (it is difficult to maintain compression). (4) Deep venous thrombosis is a contraindication to any operation on the superficial venous system, which is now the only route for blood to return to the heart. CAUTION ! (1) Pregnancy is not a contraindication. (2) If a patient is on oral contraceptives, she should change to another method one month before sclerotherapy or operation. E Q U I P M E N T Five small syringes fitted with fine needles (preferably with transparent shanks) and filled with 0.5 ml of 3% sodium tetradecyl, or 5% ethanolamine oleate. 'Sorbo' rubber pads, marking pens, suitable bandages and elastic stockings. METHOD. Treat him as an outpatient. His veins must be almost empty when you inject, and be kept empty S O that their walls adhere. Stand him up, observe, palpate, and percuss his veins; mark them with a pen. Lay him down, put his foot on your shoulder, and feel the course of his veins for gaps in his fascia (sites of incompetent communicating veins). Mark these with a pen of a different colour. Press with the tips of your fingers on as many of these gaps as you can, and, still pressing, ask him to stand. Remove your lowermost fingers first. If removing your finger from a gap in his fascia immediately causes the vein to fill, that gap is the site of an incompetent perforating vein. If it does not fill, there was no perforator in it. The sites where pressure controls the filling are the best sites for injection. Inject the lowest sites first. Bandage up to the injection site with a crepe bandage. With his leg lowered so that his vein is full, insert the mounted needle, and aspirate only as far as the transparent hub (to be sure you are in the vein); then empty the vein by raising his leg above the horizontal. Isolate the the segment to be injected by pressing with your fingers above and below it, and inject 0.5 ml of sclerosant. Apply a 'Sorbo' rubber pad over the injection site to keep it empty, bandage it on, move up to the next site, and repeat the process until all your chosen sites have been injected. Don't inject more than 5 sites. Apply an elastic stocking over the bandages, the moment the last one is secure, and immediately start him walking for an hour, and thereafter for 3 miles daily. Advise him to avoid stan- ding, and, where possible, to raise his legs when he sits. Leave the bandages on for at least 2 weeks to maintain pressure without interruption. Most surgeons leave them on for at least 6 weeks, renewing them when they become loose. If they have to be renewed, reapply them with his leg raised. CAUTION ! (1) Don't inject the sclerosant into an artery. Remember that the posterior tibial artery runs deep, near the commonest site of the perforating veins. (2) Never inject more than 1 ml at a site, because if it extravasates, the tissues may necrose. (3) Careful bandaging is critical. The pressure on both borders of the bandage should be the same. If his leg becomes painful, advise him to take an analgesic and walk. If his pain is not relieved, remove the bandage with his leg raised, and reapply it with his leg raised. At 2 weeks. If any injections are found to have failed (the vein still fills with liquid blood), reinject these sites. At 6 weeks remove the bandages. If his first leg is satisfactory, start on the other one (it is inconvenient to have both legs done simultaneously). At 6--20 weeks it may be obvious that further sites are suitable for injection. Persist until the effect is satisfactory. F L U S H LIGATION OF THE LONG SAPHENOUS VEIN INDICATIONS. (1) Incompetence of the femoral valve, causing the varices to fill from above. CONTRAINDICATIONS. (1) Obstruction of the femoral vein above the saphenous opening. (2) Deep venous thrombosis. ANAESTHESIA. (1) Give him a general anaesthetic (preferably not halothane), in a cool theatre (to reduce his peripheral blood flow). (2) Local, or (3) subarachnoid anaesthesia. PREPARATION. The evening before the operation shave his groin and leg. Stand him up and mark the vein to be operated on, and all its tributaries and pouches, with an ink that will not be washed off by the surgical scrub. Also find and mark his perforating veins, using the finger-pressure method described above. TO TIE HIS L O N G S A P H E N O U S VEIN, lay him supine with his feet apart. Give the table a 10° head-down tilt to reduce the venous pressure in his legs. Support his parted heels on foam cushions. Make a 7 cm oblique incision 1 2 cm below and parallel to his inguinal ligament, ending medially below his pubic tubercle. Deepen it, until you reach his superficial fascia. Dissect out the terminal part of his saphenous vein. Define its tributary veins (his superficial circumflex iliac, his superficial epigastric, and his external pudendal). Tie all these tributaries as they enter his saphenous vein. Tie his saphenous vein next to its entry to his femoral vein, and proximal to the entry of the tributaries. Divide his saphenous vein between ligatures of 2/0 or 1/0 multifilament. CAUTION ! If he bleeds, don't clamp blindly with haemostats, or you may damage his femoral vein, or even his femoral artery. Instead, apply pressure, and raise the foot of the table. After 3 minutes pressure you can usually control bleeding, either with a haemostat or a fine silk stitch. Tie all his other perforating veins through 3 5 cm incisions. Dissect these perforators carefully, and tie them flush with his deep fascia. F L U S H LIGATION OF THE SHORT SAPHENOUS VEIN INDICATION. Incompetence of the terminal valve of his short saphenous vein, causing the varices of this system to fill from above. METHOD. Lay him prone (see A 16.12) with his feet apart, and his knees slightly flexed. Make a transverse incision across the middle of his popliteal fossa. Make a transverse or longitudinal incision in his deep fascia to expose his short saphenous vein (which lies deep to it), and is accompanied by, and may be closely applied to, his saphenous nerve. Raise the vein, divide it, trace its proximal end down into his popliteal
at the ankle. B, the long saphenous vein with the stripper in place. C, the end of the cable emerging from the saphenous vein in the groin, with the head of the stripper attached. D, the handle of the stripper attached to the cable. E, the crumpled long saphenous vein removed with the stripper. After Sir Charles Illingworth, 'Surgical Treatment', Fig. 5, Pitman Medical, with kind permission. fossa, and tie it flush. There is usually at least one large proximal branch. Tie this. CAUTION ! The anatomy of the short saphenous/popliteal junction is notoriously variable.
F L U S H LIGATION A N D STRIPPING INDICATIONS. Symptomatic varices of either saphenous system. CONTRAINDICATIONS. (1) Deep venous thrombosis. (2) Obstruction of the femoral or other vein above the saphenous opening. One contributor considers these 'Cautions' rather than contraindications. METHOD. You will have just tied his long and/or short saphenous vein by the methods above. To strip his long saphenous vein, open it anterior to his medial malleolus. Pass the small end of the stripper up to the distal groin wound. Try to make sure that it remains in his superficial veins and does not enter his deep ones. If it sticks, or passes into a tributary, redirect it by twisting, pressure, and to and fro movements. If it will not advance, cut down on it and redirect it, or strip the vein in segments. When the stripper has passed successfully, unscrew the small head and replace it with a larger one. Tie this head in place. Raise his leg high and slowly withdraw the stripper from his groin to his ankle. Keep his leg high for a few minutes afterwards to reduce bleeding. Close his ankle and groin wounds, and bandage his leg firmly. To strip his short saphenous vein, proceed as for his long one. Enter it behind his lateral malleolus. CAUTION ! The sural nerve is closely related to the vein at the lateral malleolus. TIES A N D AVULSIONS tying perforating veins INDICATIONS. (1)To supplement tying varicose veins (with or without stripping) especially when varices are gross. (2) To treat varices and perforators after unsuccessful sclerotherapy. (3) To identify and control perforators in varicose vein surgery. (4) Post-thrombotic varicose veins. The best results are obtained early, when there are only preulcer signs, or when an ulcer has only been present for a few months. Long lasting ulcers (2 years) have a poor prognosis. Refer him. M E T H O D . Aim to pull out as much vein as you can through multiple small incisions across the vein at previously marked sites, especially where varices communicate with the main saphenous veins, or with the deep system. Raise a loop of varicose vein by gentle blunt dissection. Follow the vein as carefully as you can in each direction and along other connecting veins as you find them. When you have exposed a length of vein pull it out. There is usually no need to tie it unless it is large or perforates the deep fascia. Close small incisions with adhesive tape unsutured (54-7). For the subfascial tying of perforators see below under varicose ulceration. POSTOPERATIVELY (after flush ties, long and short saphenous vein stripping, and multiple ties and avulsions, and tying perforators). Don't let him stand at first, and only let him sit when necessary for meals and toilet purposes. Let him walk actively as soon as he is comfortable, and as soon as possible for 1 hour daily. Most patients can go home the same day. Leave the pressure bandage applied at operation until the 6th day, then remove the stitches. Tell him to wear elastic bandages for another fortnight. VARICOSE ULCERATION DIAGNOSIS. Most lower leg ulcers in the tropics are chronic tropical ulcers (31.2). Varicose ulcers due to incompetent perforators are less common. A varicose ulcer is usually on the lower third of the leg, especially just behind and above the medial malleolus. It may be of any size and shape, its edges are usually brown and eczematous, and it has red granulations under the slough on its base. The patient is usually fat. Progressive fibrous atrophy of the subcutaneous of his lower leg ('inverted bottle leg'), and brown pigmentation, may precede ulceration. He may have either or both: (1) Gross primary varicose veins of many years' standing (most primary varicose veins don't lead to ulceration). (2) Incompetent deep perforating veins (50% of varicose ulcer cases), which may be not be easy to find under his ulcer. THE DIFFERENTIAL DIAGNOSIS includes: (1) Chronic ulcers starting as tropical ulcers (31.2). (2) Ischaemic ulceration (feel his pulses). (3) Squamous cell carcinoma (which may develop in any chronic ulcer, 32.19). (4) Buruli ulcer (31.2a). (5) Factitious ulcer. TREATMENT Put him to bed with frequent sterile saline soaks until his ulcer is clean and oedema has gone. Either: (1) Apply strong elastic webbing bandages capable of withstanding 100 mm Hg from the base of his toes to just below his knees, over a plain non-adherent dressing. Ask him to remove the bandage at night, to clean his ulcer, to sleep with the foot of his bed raised, and to reapply the bandage each morning. Recent (3 months) ulcers will often heal this way; but he should wear an elastic stocking for life. Or, (2) if his ulcer will not heal or keeps breaking down again, and you can find the venous abnormality, treat it by injection and/or operation. This is usually easy if his varicose veins are primary (uncommon), but is more difficult if they are secondary (common). If venous insufficiency due to incompetent perforators, is the cause of persistent ulceration, consider referring him to have these tied by a subfascial approach (eg. Cockett's operation). The commonest perforator responsible is usually within 2 cm of the upper border of the ulcer. DIFFICULTIES WITH VARICOSE VEINS If varicose veins BLEED, haemorrhage can be alarming. Lay him down, apply pressure to the bleeding vein, and then tie it. If an INDURATED LINE, develops along the course of the stripper, reassure him that it will usually be gone in a month. If you INJURE HIS SAPHENOUS VEIN during surgery, see Section 32.34D. THE S U R G E R Y OF T H E SKIN
Hypertrophic scars and keloids
A surgical scar, especially if it is on the face, should, if possible, be nearly invisible. Sometimes a scar becomes very visible indeed as the result of two processes: (1) hypertrophy and (2) keloid formation. Both these processes can follow surgery, tribal scarring, an injury, or almost any breach of the skin surface. Both cause large scars, and are identical histologically, but they behave differently. Hypertrophic scars are common, wide, and raised. They are bright pink (in a light skin), are uniform, and do not extend beyond the edge of the original incision. They itch, and may be painful. They continue to thicken for 3 to 18 months, then become static, and finally resolve to become broad, soft, thin, and level with the surrounding skin; the whole process taking about three years. Keloids are less common, but are not unusual in African patients. They are also wide and raised, but the new tissue grows beyond the original confines of the scar to form irregular mounds of collagen, which resemble benign tumours. Keloids may not start to form for many months after the original breach of the skin surface; they grow for a year or more, and then stop. There may be so many of them, and they may be so large, that they disfigure, deform, and disable the patient. Keloids are difficult to treat. If you excise one through normal skin and graft the gap, it is likely to recur round the edges of the graft, or in any gaps or splits in it. Both a hypertophic and a keloid response are more likely if a wound is: (1) Infected. (2) Contaminated by foreign material- even monofilament sutures may promote them, but are less likely to do so than multifilaments. (3) Under tension. (4) In a young adult. (5) In a vascular part of the body (you will seldom find them on the legs or feet). (6) In a black-skinned patient.
about 8 months previously. Patient A, has formed a keloid on her vertical scar. Patient B's transverse (Pfannensteil) incision in her skin crease has healed almost invisibly. Scars in skin creases are not under tension and form less keloid. After Charles Bowesman, 'Surgery and Clinical Pathology in the Tropics' E and S Livingstone, with kind permission. THE PHYSIOLOGY OF KELOID FORMATION. Normally, there is a balance between the anabolic and catabolic stages of wound healing. As a wound heals, it goes through various stages. At about 3 or 4 weeks it is hyperaemic, and its strength is still only about a third that of normal skin. During the following 2 or 3 months, the hyperaemia subsides, and the scar becomes flatter and more pliable; at about 3 months it reaches its definitive state. In an abnormal scar there is no equilibrium at 3 or 4 weeks, the anabolic phase continues, hyperaemia increases, more collagen is layed down, and the wound expands and becomes wider and raised. It may develop into a hypertrophic scar or a keloid. Both are stronger than a normal scar. T H E KELOID RESPONSE
T H E DIFFERENTIAL DIAGNOSIS may be difficult early on. Suggesting a hypertrophic scar--abnormal growth starting within weeks of the injury, growth restricted to the confines of the original scar, spontaneous regression in months to 3 years, anywhere in the body, commoner than keloid in a white skin, very common in burns scars, itching is common and may be severe. Suggesting a keloid--an onset delayed for months or years, invasion of the surrounding skin, growth stops in due course but there is no regression, localized to some parts of the body, not uncommon in black patients, uncommon in burn scars, very uncommon below the groin. If diagnosis is difficult, remember that a keloid becomes increasingly raised, and extends beyond the confines of the original scar. T H E P R E V E N T I O N OF KELOIDS AND HYPERTROPHIC SCARS Minimize tension in the scar. Scars in the line of skin creases are under less tension than those across it. So plan incisions in skin creases where possible. If you have to cut across a crease, consider using a Z-plasty (57.11). If possible, avoid scars in areas that are normally under tension: In the neck especially. In the coronal plane in the upper arm, especially its lateral side. In the the upper back. CAUTION ! Midline scars over the sternum and longitudinal incisions in the arm are particularly likely to develop keloids- they cross the skin's creases. Maintain careful asepsis, minimize trauma when you operate, and control bleeding carefully at the end of the operation. Don't pull sutures too tight, and avoid mattress sutures. POSTOPERATIVELY If a patient is particularly likely to develop a hypetrophic scar or a keloid, as shown by his previous history, apply pressure to the scar for to months after the operation. Ideally, an elastic garment should be made to fit. This is unlikely to be practical, but you may be able to cut a piece of foam rubber to fit a smaller scar, and hold it in place with an elastic bandage. Tell him not to remove it except to wash. Unfortunately, both an elastic garment and an elastic bandage are are difficult to tolerate for long, especially in a hot climate. T R E A T M E N T FOR KELOIDS AND HYPERTROPHIC SCARS A H Y P E R T R O P H I C S C A R . If possible, leave it; often, it is not disfiguring. Reassure him that it will eventually regress naturally. Never operate during the active phase. If you decide to operate, do so during the mature phase, years or more after the original wound. Then, excise the scar, and apply the preventive measures above. Considerable improvement is possible. If he presents earlier than years, before a scar is mature, apply pressure, as above. A KELOID. Treatment is more successful if you start it early. BOWESMAN'S METHOD FOR KELOIDS A A developing keloid. Within a month or two of the injury: (1) Apply pressure. (2) Inject a suspension of hydrocortisone, about 2 ml at each site spread out subcutaneously. Or, better, use triamcinolone. Give 4 injections 3 weeks apart. An established keloid. Steroids have no effect. Resist the request to operate if you can. The worse the keloid, the more likely it is to recur if you excise it. If you are pressed, excise smaller ones, but be sure to explain that they may recur and may even be worse. If you operate, excise the abnormal tissue within the keloid, leaving a margin of keloid tissue all round. Keep your sutures within this margin also. If necessary, graft the bare area. You may be able to shave skin off the keloid and use this as a graft. All this is difficult; so is closing the wound tidily. Complete the incision and then inject steroid suspension into the scar. Postoperatively give him 4 more steroid injections at 3-weekly intervals. Apply a pressure bandage or an elastic garment for 9 months--if he will accept it! Alternatively, follow the method of Bowesman in Fig. 34-5. Keloids are easier to remove from convex than from concave surfaces. A protruding keloid usually extends downwards like a saucer into the subcutaneous fat. Shave it off a little above the skin level, remaining within the keloid tissue and without entering the subcutaneous fat. Control bleeding, and apply a com- plete sheet of split skin extending beyond the margins of the keloid. CAUTION ! (1) Try to avoid operating on established keloids. (2) Use a sharp knife. (3) Don't pull on the keloid as you excise it, or you may enter the subcutaneous tissue. Instead, if necessary, depress the surrounding tissues. (3) Don't use sutures.
Granuloma pyogenicum
When a wound heals, especially an infected one, new granulation tissue forms. If this is so excessive as to make an obvious lump, you can mistake it a tumour. A pyogenic granuloma can occur anywhere, but is commonest on the face, fingers, or toes, as a soft or moderately firm, dull red, 1 cm lump, covered with atrophic epidermis or crusts, and which bleeds easily. This trivial lesion can be misdiagnosed and thought to be a sarcoma, when all that is needed is simple excision and curettage. An antibiotic is only needed if there are signs of spreading infection (very unusual).
Sebaceous and dermoid cysts
When the mouth of a sebaceous gland is blocked, retained sebum causes it to form a cyst. Sebaceous cysts are most common on the face, scalp and back, as hemispherical firm or elastic swellings, with no obvious edge, which are adherent to the skin. They are filled with putty-like yellowish white sebum, which you may be able to indent with your finger. Three complications may follow: (1) A sebaceous cyst can become infected; this makes it enlarge and become red and painful. Recurrent infection makes it adhere to the surrounding tissue, and become more difficult to remove. (2) It can ulcerate, and discharge its contents. The lining membrane which is left can then resemble an epithelioma. (3) Its contents can escape, and become hard and form a sebaceous horn.
S E B A C E O U S CYSTS. Paint, drape, and if necessary shave the area. Under local anaesthesia (A 5.4), incise an ellipse of skin over the swelling, in the direction of the natural lines of the skin. This is particularly important in the face, see Fig. 61-3. Deepen the incision until you reach the edge of the cyst. Push the points of fine curved scissors between the cyst and the tissue round it, and then open them, so as to define a plane for dissection. Repeat this all round the cyst until it is free, then remove it with a snip of the scissors. Press firmly with dry gauze for 5 minutes to stop bleeding. If any bleeding vessels remain, tie them off. Close the skin, leaving a small corrugated drain in place. Remove this at 48 hours. D E R M O I D CYSTS. Lumps very like sebaceous cysts from at the lines of skin fusion in the embryo, most commonly at the lateral end of the eyebrow where the maxillary and ophthalmic divisions of the face meet. Manage them as for sebaceous cysts.
The management of snake bites
Fortunately, most snakes have no fangs and are not poisonous. When a snake does have fanes, these can be at the back, or the front of its mouth. If the fangs are at the back, it is usually harmless, an important exception being the African boomslang (tree snake). If the fangs are at the front it is usually poisonous. Apart from a few islands, there are venomous snakes almost everywhere; but only a few are medically important. Being bitten by one, usually on the leg, is one of the risks of being a tropical villager. People who deliberately handle snakes are usually bitten on their hands or arms. Although many people are bitten, less than half are poisoned, even by a poisonous snake, and of these few die. The danger is that a snake will inject its full dose of poison, in which case the patient has about a 50% chance of death, unless he is treated. Many snake bites are treated by traditional practitioners, and of the patients who do arrive in hospital, many arrive late. If necessary, teach your paramedical staff to treat snakebite, and supply them with antivenom. Snake toxins have a variety of effects, depending on the species. These include local swelling, capillary oozing, and necrosis; generalized damage to muscles (sea snakes), damage to the heart or kidneys, interference with blood clotting, haemolysis, and various neurotoxic effects. If a patient is treated symptomatically, he usually recovers, but if his symptoms are severe he needs the specific antivenom, ideally in monovalent form, or failing this as a polyvalent mixture suitable for the common snakes of the area. Theoretically, a monospecific antivenom is better, because smaller volumes are required, and this reduces the incidence of serum reactions. In practice, a polyvalent antivenom is more satisfactory in the rural tropics. Antivenom can occasionally cause reactions which are fatal, so don't give it unless it is indicated, and always have adrenalin ready. For sources of specific sera for your local snakes, see below. In view the potential dangers of antivenom, its cost, and the difficulty of stocking it in sufficient quantities in remote places, controllled ventilation, by any of the methods in 'Primary Anaesthesia' (A 13.1), is the main method of preventing death in a patient with severe neurotoxic symptoms following the bite of an elapid snake. You should know which snake bit him; but a patient often does not know this, particularly if he was bitten at night. Globally, the carpet or saw-scaled viper, is the most dangerous snake, because of its wide distribution (particularly West Africa, Pakistan, and North West India), its abundance in farming areas, its good camouflage, its irritability, and its toxicity. Manson-Bahr PEC, and Apted FC, Sanson's Tropical Diseases'. BailliereTindall. Reid HA and Theakston RDG, The Management of Snake Bite'. Bulletin of the World Health Organization 1983;61(6):885-895. Progress m Characterising Venoms and the Standardisation of antivenoms', 1981 WHO Offset Publication No. 58. T R E A T T H E P A T I E N T N O T T H E S N A K E S N A K E BITES
FIRST AID. A snake bite is frightening, so reassure the patient. Move the bitten part as iittle as possible. If at any time he vomits or loses consciousness, turn him into the recovery position (A 4-5). CAUTION ! (1) If the snake has been killed, keep it for examination, but don't try to look for it. (2) Don't handle snakes, even dead ones; decapitated heads can bite for some hours.
(3) Don't inject antivenom as part of first aid treatment. (4) Wipe, but don't incise the bite. C R E P E BANDAGING. The traditional arterial tourniquet is now outmoded, because of its dangers. Instead, apply a firm crepe compression bandage over the whole length of the bitten limb, to slow the spread of venom. Remove it after about 8 hours. IN HOSPITAL Admit him. Don't panic or rush to inject antivenom. If he demands an injection, give him tetanus toxoid (which he needs anyway). Raise a bitten leg, and put a bitten arm in a sling. Clean the site of the bite and leave it open. Keep the number of injections to a minimum, because he may bleed from the injection sites, if the venom (particularly from a viper) alters blood clotting. Set up a drip. If there is local necrosis, give him a broad-spectrum antibiotic; some surgeons give them routinely. Avoid aspirin, because of its adverse effects on platelets, and morphine, which may mask respiratory depression. CAUTION ! (1) Don't incise the bitten area, or apply ice or dressings early on. (2) Don't give heparin, fibrinogen, or neostigmine. (3) Steroids are useful for delayed {not immediate) serum reactions. HAS THE S N A K E INJECTED POISON? If his symptoms are immediate, he is probably only frightened; symptoms of poisoning rarely appear before half an hour, although they can ap- pear in the first 5 or 10 minutes. Fang marks are of little help; there may be marks and no poisoning, or no obvious marks and poisoning. Local pain can be severe when there is no poisoning, and be absent when there is poisoning. Three early non-specific signs suggest poisoning: (1) vomiting, (2) a polymorph leucocytosis and (3) hypotension. If this is accompanied by a slow pulse, suspect a strong vasovagal compo- nent to the symptoms, and thus a good prognosis. Other early non-specific signs are headache, abdominal pain, explosive diarrhoea, and collapse with an unrecordable blood pressure. These symptoms usually resolve spontaneously within an hour. After a viper bite a patient's blood fails to clot, his gums bleed, blood appears in his sputum and he may bleed from an old wound. After an elapid bite his eyelids droop (ptosis). If there is local swelling which starts a few minutes after a viper bite, venom has been injected. This is not a criterion for giving antivenomn: wait for signs of specific poisoning. If there is no swelling a few minutes after a viper bite, you can be sure that no venom has been injected. If there is no pain and swelling and no general signs 2 hours after the bite, it is very unlikely that the snake is dangerous. However, signs can occur after a few minutes or be delayed for 12 hours, so observe him carefully. WHAT KIND OF S N A K E WAS IT? Identifying the snake can be important, because it will allow you to give specific monovalent antivenom (if you have it); but not being able to identify it should never delay treatment. Here are some of the typical syndromes. Vipers usually cause massive local swelling, due to exudation from injured capillaries; abnormal bleeding; and blood which fails to clot; later there is necrosis and gangrene. Elapids are the cobras, mambas, kraits, and coral snakes. Their effects are mainly neurotoxic. Paralysis varies, and may be extensive and fatal. He has difficulty breathing due to respiratory paralysis, and cannot swallow. Ptosis is the earliest sign. Sea snakes are myotoxic, see below. LOCAL S W E L L I N G starts minutes after the bite of a viper, and may be massive after 72 hours. The swollen area may be bruised, blistered, and ultimately necrotic. Wet gangrene may develop rapidly over days (cobras), or dry gangrene slowly over weeks (vipers). If there is no necrosis, recovery is rapid, provided that the fluid lost into the tissues is replaced. Swelling and necrosis are not usually dangerous in themselves, although they may result in permanent scarring, or occasionally in the need for amputation. If there is any swelling, expose his limb to reduce its temperature. Raise his arm in a roller towel (75-1), and his leg by raising the foot of his bed. Leave his blisters undisturbed. If his tissues necrose, excise sloughs and graft early. Necrosis is usually confined to the subcutaneous tissues, without involving his muscles and tendons. Apply saline dressings, and graft the raw areas (57.1). Antibiotics are not helpful, unless and until there is local necrosis. If he presented very late, you may have to amputate. Very rarely, fasciotomy may be necessary (81.14). SHOCK, starting later, is the main cause of death in viper bites. It can be late or early, sometimes within a few minutes of the bite, with abdominal pain, explosive diarrhoea, collapse and an unrecordable blood pressure. If it is due to hypersensitivity to the venom, rather than to its toxicity, these symptoms may resolve spontaneously in half an hour. If he is in hypovolaemic shock give him saline. This is cheaper and more readily available than plasma, and less likely to infect him with HIV. If he shows signs of hypovolaemia, give him 2 litres of saline quickly initially. If he shows signs of circulatory insufficiency and extensive bruising, give him blood. Blood is particularly useful if he was anaemic before he was bitten, or if antivenom is not available. B L E E D I N G may occur from the bite, into injection sites, in his vomit, from his gums, under his skin, or into his brain. It is often lethal, and may be delayed for several days. Hess's test may become positive in 30 minutes. Hess's test Blow up a blood pressure cuff to 80 mm Hg and leave it on for 5 minutes. If a crop of purpuric spots appears below the cuff, the test is positive. The clotting test gives warning of bleeding to follow. Keep some blood in a tube horizontally for 10 minutes and then tilt it. If it fails to clot, he needs antivenom. In Africa non-clotting blood is a useful indicator of Ekhis envenoming, for which there is a specific antivenom. If he bleeds extensively, and you have no antivenom, transfuse fresh blood, and if necessary give him fibrinogen intravenously. NEUROTOXIC EFFECTS are characteristic of elapid poisoning, and are the result of a selective neuromuscular block. Ptosis is the earliest sign (don't confuse this with sleepiness). Other effects include: inability to cough, protrude the tongue, smile, or move the lower jaw; drooling, dysphagia; partial, flaccid limb paralysis, more marked proximally (painless, except in the case of sea snakes, when the paralysis is painful), generalized f a s c i c u l a t i o n s , vertigo, c o n v u l s i o n s , unconsciousness, respiratory failure from intercostal paralysis, squint, speech incoordination, and generalized paraesthesiae. If his neck and trunk muscles are involved, he is unable to lift his head or sit up. The important fatal effects are respiratory failure, and failure of his swallowing reflex. Respiratory failure may manifest itself as increasingly shallow respirations, or as a vigorous struggle for air with laboured breathing. If necessary, intubate (A 13.2) and ventilate (A 13.1) him in the theatre, while you wait for the antivenom to become effective. For the signs of incipient respiratory failure needing ar- tificial ventilation, see A 19.4. CAUTION ! (1) Intubation and ventilation are the first priority. Antivenom comes second, once he is breathing. (2) The in- halation of secretions, or stomach contents, can cause sudden death at any time (A 16.3). MYOTOXIC EFFECTS are characteristic of sea snakes. Early symptoms are muscle pain and stiffness anywhere, but particularly in his neck, tongue, and throat. This is soon followed by tenderness, pain on passive movement, muscle weakness, and myoglobinuria. His muscles may take months to recover. ANTIVENOM INDICATIONS. (1) Undoubted clinical symptoms of systemic poisoning. Antivenom may still be effective hours or days after the bite. It is never too late to give it. CONTRAINDICATIONS. Enquire for a history of allergy; this increases the risk of an allergic reaction. A known allergic history contraindicates antivenom, unless the risk of death from envenoming is high. There is no point in doing a sensitivity test, because it is unreliable, and if he is seriously poisoned, he will need antivenom anyway. Give all patients promethazine. This will promote sleep and relieve apprehension, and may minimize sensitivity reactions (rarely severe). METHOD. Ideally, the venom should be monovalent, but some broad-spectrum polyvalent antivenoms are sufficiently active. Even if an antivenom is out of date, it may still be effective. If it is opaque when you make it up, discard it, because there will be a greater risk of reactions. Give him 20 to 50 ml of antivenom, diluted in 3 volumes of 0.9% saline. Give it by intravenous infusion diluted in a drip, or by slow bolus injection. The dose depends on the type of antivenom, and the type of snake; you may need much more than 40 ml, especially after an elapid bite. In severe poisoning (especially with neurotoxic envenoming) give 100 to 150 ml. In children give the same dose as in adults. Start the drip slowly (15 drops a minute). If there is no initial reaction, increase the speed of administration, so that you can complete the infusion in 1 to 2 hours. If there has been little improvement, give more. If there are signs of sensitivity to antivenom (pallor, hypotension, dyspnoea, laryngeal oedema), temporarily stop the drip and inject 0.5 ml of 1:1000 adrenalin subcutaneously, over some convenient part of his chest. This is almost always effective, and you can then restart the drip. If he has an allergic history, give him small doses of adrenalin (0.5 ml of 1:1000 adrenalin) subcutaneously, before you give the antivenom, and repeat it if a reaction occurs. Also, give him promethazine or hydrocortisone 100 mg to protect against sensitivity reactions (rarely severe). If more than 2 hours have elapsed since the bite of a known front-fanged (elapid) snake, and life-threatening signs are obvious, give the antivenom intravenously without delay, and without testing for hypersensitivity, under steroid or antihistamine cover. In sea-snake poioning, give 3000 to 10,000 units of antivenom. In mild poisoning 1000 to 2000 units should be enough. CAUTION ! (1) In all patients, have adrenalin ready in a syringe, and give it at the first sign of anaphylaxis (pallor, etc., see above). (2) Don't give antivenom to all patients routinely. MONITORING Record his pulse, blood pressure, peripheral circulation, and respiration hourly, and the circumference of his bitten limb at the site of the bite. Monitor his urine output and his blood urea. Watch for specific signs, and don't discharge him for at least 12 hours. DIFFICULTIES WITH SNAKE BITES If, immediately after the bite, he appears SEMICONSCIOUS, and cold with clammy skin, a feeble pulse and rapid breathing, this may be due to fright (try a placebo injection), or to venom effects. In some venoms these pass off spontaneously in half an hour. If he is MENTALLY CONFUSED, suspect respiratory failure. If he shows signs of GLOSSOPHARYNGEAL PALSY (difficulty swallowing), nurse him in the recovery position. If confusion, stupor, or RESPIRATORY FAILURE develop, intubate him, and aspirate his secretions. Atropine may diminish them. If he develops signs of RENAL FAILURE (vipers, elapids or sea snakes), they usually appear towards the end of first week. Avoid drugs which are excreted in the urine (except for penicillin when necessary); treat him as in Section 53.3. If a spitting COBRA SPAT INTO HIS EYES, wash them out with a large quantity of water, and tell him to blink. The venom is quickly diluted and causes no harm. V E N T I L A T E H I M A N D H E W I L L P R O B A B L Y L I V E RADIOLOGY
Some X-ray methods for the generalist
Section 1.13 describes W H O ' s basic radiological system. Here are some methods which are not part of that system. If you have a radiographer, he will be familiar with them. Most of them assume that your machine has a screen, but it has not, you can still do a barium swallow. Always use a grid which will improve the definition. Most screens have a grid which you can slide into place. Carcinoma of the oesophagus is common in much of the developing world, so you will find a barium swallow, which is quite easy, particularly useful. A barium meal is more difficult, but with reasonable practice you can learn quite a lot from one. A barium enema is more trouble, and is less often needed. Cystoscopy (23.3) may give you the information you need, and is cheaper than an IVU. We do not describe catheterizing the ureters, and so retrograde pyelography is not described either. INTRAVENOUS U R O G R A M (IVU) (intravenous pyelogram or IVP) INDICATIONS. If a patient has moderate impairment of his renal function, to see if it has a purely renal cause, or is due to an obstructive uropathy, particularly a hydronephrosis or a ureteric stricture, especially in areas where S. haematobium is endemic. To see if a mass is renal. To assess the function of his other kidney, when you consider referring him for nephrectomy. Renal trauma Renal or ureteric stone (23.12). CONTRAINDICATIONS. (1) Measure his blood urea. If it is over 10 mmol/l mg/dl), an IVU will probably fail because the dye will not be excreted in adequate concentration to be visible. It is certainly not worth doing if his blood urea is over mmol/l (100 mg/dl. Renal failure. Hepatic failure, which may be aggravated. Cardiac failure; there is a risk of arrythmia. (4) Dehydration. Infancy. The first trimester of pregnancy is a relative contraindication, but the danger is minimal. Any previous reaction to contrast medium or other allergic disease. (8) Multiple myeloma. PREPARATION Starve him overnight and give him an aperient to empty his gut. Air will not spoil the film, but a mixture of air, fluid and faeces will. Don't give him an enema. If the IVU is urgent, do it without preparation. R e t r o g r a d e u r e t h r o g r a m
C O N T R A S T M E D I U M . Use 'Urografin* or 'Conray 420'. Rarely, he may have a reaction, so make sure you have ready 0.5 ml of adrenalin and promethazine mg for intramuscular injection. Cardiac arrest has followed injection, so be prepared to resuscitate him (3.5). FILMS. Use 18x24 cm for his bladder; 24 x 30 cm for his renal area; 30x40, 35x35, or 35x43 cm for his whole abdomen. M E T H O D . The following method minimizes the number of plates needed. The views are all A P ; mA at KV should be enough for a kg adult. Lay him supine on the X-ray table. Take a preliminary view of his abdomen and pelvis on a 30x25 cm plate, before giving the contrast medium. Give him ml intravenously as quickly as possible. At minutes take a 25x 30 cm plate of his kidneys. Then compress his lower ureters. If his calyces are obviously normal at 3 minutes (be quick, it will need minutes in the developer, fixing and washing), you can omit the minute film. At minutes take another view of his kidneys. At minutes release the compression and then quickly take a 35x43 cm plate to show his ureters and bladder. At minutes ask him to empty his bladder, and then take a small plate to show his residual urine. If the function of his kidneys is impaired, so that there is little excretion in the standard films, repeat them at hours, and if necessary at hours. R E T R O G R A D E U R E T H R O G R A M FOR A STRICTURE PRINCIPLE. If you inject contrast medium up a patient's urethra from below, you can outline his distal urethra up to the face of the stricture. INDICATIONS. Stricture of the urethra. Congenital anomalies. Prostatic abscess. Fistulae. False passages. CONTRAINDICATIONS. Acute infections of the urinary tract. Recent attempts at bouginage which will increase the risk of bacteraemia. C O N T R A S T M E D I U M . (1) A contrast medium especially designed for urethrography, such as 'Umbradil Viscous U'. If necessary you can probably dilute it with an equal volume of water and still get good pictures. (2) If necessary, use media designed for urography, such as 'Hypaque' 4 5 % and urografin 6 0 % . CAUTION ! Don't use barium, or an inorganic iodide. Contrast medium readily passes into the surrounding vessels. METHOD. Using aseptic precautions, insert a 16 Ch Foley catheter for 5 cm only into his urethra. Gently inflate the bulb with 1 or 2 ml of sterile water. The expanded bulb will now fix the catheter in his fossa navicularis. Fix a length of tubing to the catheter. You can now position him more easily, and be further from the radiation yourself when you inject the contrast medium and expose the plate. Inject the medium and take an oblique film while he lies on the X-ray cassette. Avoid extravasation, if you can. If his bladder is reasonably fi4led, you can follow a retrograde urethrogram with a micturating cystourethrogram. The membranous urethra is separated from the penile urethra by a line, which runs from the junction of the upper third and the lower two-thirds of the pubic ramus on one side, to a corresponding point on the other side. MICTURATING CYSTOURETHROGRAM F O R A S T R I C T U R E PRINCIPLE. This shows up the proximal face of a patient's stricture, and will also show bladder neck stenosis. His bladder must be filled with contrast medium to begin with. If you can pass a catheter through his urethra, you can fill it that way. If he has a suprapubic catheter in place and is able to micturate through his urethra (unusual), you can fill his bladder through that. INDICATIONS. (1) Strictures. (2) Suspected abnormalities of the bladder neck. (3) The assessment of vesical diverticula. (4) Cysto-ureteric reflux. CONTRAINDICATIONS. (1) Acute infections of the urinary tract. (2) Recent attempts at bouginage, which will increase the risk of bacteraemia. C O N T R A S T M E D I U M . (1) 40 ml of 6 0 % 'Urografin' in 400 ml of saline. Or, (2) a 250 ml bottle of 3 0 % 'Urografin'. (3) 400 ml of 12.5% sodium iodide with 0.1% sodium metabisulphite. This is the cheapest. The sodium iodide must be suficiently pure; small quantities of fluoride in it can be disastrous. METHOD. This depends on whether or not he already has a suprapubic catheter in place. If he has a suprapubic catheter, empty his bladder through it. Using an intravenous drip set or a large syringe, fill it through his suprapubic catheter with 300 to 400 ml of contrast medium until he has a strong desire to pass urine. Take an erect oblique AP film at 80 mA and 80 kV while he is standing to pass urine. Or take an oblique film in the lying position; there will be less blur due to movement. Use a bucky screen and a grid cassette. If he has a ureteric catheter in place, fill his bladder through that. BARIUM SWALLOW
INDICATIONS (1) Dysphagia. (2) Carcinoma of the oesophagus (32.24). (2) Post-corrosive strictures (25.15). CONTRAST M E D I U M (1) Thin barium ('Gastrografin' or 'Endographin'). Water-soluble media must not be aspirated. (2) Barium sulphate; thicker than for a barium meal, yet not so thick as to aggravate an obstruction. CAUTION ! Don't use barium carbonate, which is highly poisonous. METHOD. Stand him in front of the X-ray screen facing you. If you don't have a screen, take films only. Ask him to fill his mouth with contrast medium, but not to swallow it until you ask him to. He can either drink from a feeding cup (which is less likely to spill in the dark), or suck the barium through a stiff 5 mm plastic tube inserted through a hole in the top of a plastic container, as used for tablets. The mixture of air and
barium that he swallows will produce an informative 'phase contrast' film. Adjust the X-ray machine to provide a narrow vertical aperture. Then ask him to swallow and watch the barium pass. Repeat the process and expose a plate as he swallows. Do the same thing while he stands laterally with his hands above his head. You should be able to see all but the upper end of his oesophagus quite easily. If necessary, take two oblique views, a lateral fiew and an AP view. Carcinoma of the oesophagus causes a narrowing with an abrupt start and an irregular rounded shoulder; above it the oesophagus is either not dilated, or only a little dilated. The lumen through the tumour is irregular and is typically rat-tailed, and you can see the end of the stricture. You should be able to demonstrate 9 0 % of carcinomas with simple screening. An ordinary PA film may show widening of the mediastinum. Be sure to use a long plate to get his whole oesophagus on to it, and don't cone down. If no screening is available, a mouthful of contrast medium and one large film will usually show the tumour. If you are not sure how long the stricture is, try a repeat film with a head-down tilt. This is important in deciding how long a Celestin tube needs to be (32.24). Achalasia (uncommon) shows as a 'bird's beak' at the bottom end of a greatly dilated oesophagus. Take oblique films. Corrosive oesophagitis produces a stricture which is usually long and irregular. A post-cricoid web (rare in Africa) is associated with iron deficiency anaemia and is a narrow web behind the cricoid cartilage. Centre a lateral film on the cricoid. BARIUM M E A L INDICATIONS. (1) Bleeding from the upper gastrointestinal tract, oesophageal varices (endoscopy is likely to be preferable). (2) Peptic ulcer. (3) Carcinoma of the stomach. (3) Carcinoma of the head of the pancreas. (4) An upper abdominal mass suspected of being gastric. METHOD. Do a barium swallow first with thin barium. Ask him to stand facing you. Then give him thicker barium. Adjust the aperture of the X-ray machine to let you see his entire stomach. Stand him facing you, and ask him to drink enough barium to about half fill his stomach while he continues to stand facing you (one contributor uses much less barium). Then screen him in this position and in the left oblique position (he should look beyond your left shoulder), or use the right oblique position. S T O M A C H . Watch peristalsis carefully. Does barium pass through normally all the way to his pylorus? Suggesting carcinoma--an immobile area, a persistently irregular surface, a consistent filling defect (this makes carcinoma very likely). Suggesting a gastric u l c e r -a n ulcer, usually on the lesser curve, in the distal half of his stomach. Expose 1 to 3 plates, asking him to hold his breath as you do so. To look for a hiatus hernia you will need to raise his intraabdominal pressure: (1) Ask him to lie down and give the table a 20° head-down tilt. Push the barium up to his fundus, and expose another plate. Or (2) ask him to lift his legs off the table and cough. DUODENUM. Note if there is delay in the passage of barium through his pylorus: it should start passing at 1-5 minutes. Use the special attachment which will exclude all X-rays except those in a 10 cm circle. Turn him to face obliquely to your right as far as is necessary for you to see his pylorus and duodenal loop. Expose plates as the barium passes. You may be able to recognize a deformed duodenal cap while you screen him, but you will see scarring or a duodenal ulcer more easily on the dry films. With experience, you will recognize enlargement of the duodenal loop (as by carcinoma of the head of the pancreas). Pyloric delay makes a duodenal ulcer or a carcinoma of the distal antrum likely, and is an indication for laparotomy. BARIUM E N E M A INDICATIONS. (1) Suspected amoebic strictures. (2) Carcinoma of the large gut. (3) Diverticulosis (rare in most of the developing world). (4) A mass which might be colonic. (5) Ulcerative colitis, tuberculosis, Chron's disease etc. CAUTION ! A barium enema should follow proctoscopy and sigmoidoscopy, which will often establish the diagnosis more easily and cheaply. CONTRAINDICATIONS. (1) Complete, incomplete, or impending intestinal obstruction. (2) Rectal biopsy immeditely preceeding the enema. EQUIPMENT. An X-ray machine with a screen. A 2 litre douche can. 2 metres of 30 Ch rubber or plastic tube. 2 large artery forceps. A Higginson's syringe. A grid on top of the X-ray plate. METHOD. Prepare the patient with an enema, and a thorough washout (not merely an enema, and not necessary in children), within the previous 12 hours, and keep him on fluids during this time. Use barium/air contrast with the equipment in Fig. 34-11. CAUTION ! Manipulate the flatus tube with gloves. Have toilet paper and a bedpan ready--it may be required urgently! Lay him supine on the X-ray table, and ask him to flex and abduct his hips. Protect his gonads. Lubricate the flatus tube
well with KY Jelly, and push it through his anus, as far as it will go easily. Ask him to extend his legs on to the table. Inject barium and air, as required, to show his large gut up to his caecum. Inject a fair amount of barium first, and follow this by pumping air with the Higginson's syringe to move the barium proximally, clamping and releasing the tubes as necessary. Instil some barium, and then some air. You will probably be able to demonstrate his large gut as far as his hepatic flexure, without much difficulty; his ascending colon is more difficult. The limiting factor is the distension of his large gut with barium and air, and the urge to defaecate that this produces. If he feels much discomfort, wait 2 or 3 minutes and try again with more barium and more air. Watch the movement of barium and air on screening, and expose plates of critical areas. Before he defaecates, which he is usually keen to do without delay, take a standard abdominal X-ray after removing the screen and keeping the grid in place. Expose another plate after evacuation. The film of barium left on his mucosa will often give the clearest picture. Finally, remove the flatus tube and let him pass the contents of his gut into the bedpan. EVALUATION
Indicators of quality in district hospital
surgery How can you know that surgical care in a hospital is good? What should a visitor look for when he goes round your hospital and what questions should he ask? Here are a few suggestions. INDICATORS OF QUALITY IN S U R G E R Y The hospital has a plan as to which day of the week non-urgent operations are done, and when clinics are held. Ward rounds are held daily. Each patient has a plan in his notes saying what should happen to him and when--when a cast should come off, when trac- tion should be taken down, or a burn should be grafted, etc. There are accurate notes in enough detail to enable another doctor to take over. The staff wash their hands after examining a potentially infected patient, before examining the next one. Not to do so, especially after examining an infected wound, is the height of bad practice--presuming, of course, that the ward has water, which, alas, some do not. Patients are washed thoroughly with soap and water before surgery--especially the operation site. How often do clean operations in your hospital become infected? (2.10) How many skin grafts do you do, and how many of them take? (57.1) How much knee movement do your patients have when you discharge them from hospital after you have treated their broken femurs? (78.3) Are all patients whose fractures have been put in plaster, told to to return immediately if they get pain? (70.4) Are there any instruments or equipment, which were broken more than a month ago, which no attempt has yet been made to replace or repair? Is some provision is made to provide terminal care for cancer patients? (33.1) Do you know your mortality rate for the more common o p e r a t i o n s ?
Indicators of quality in district hospital
obstetrics The critical indicators are the maternal and perinatal mortality rates, and indeed whether you have worked them out. Where obstetric care is good, mothers almost never die, so that almost any maternal death is likely to indicate care that is not as good as it might be. Another useful indicator is the variety of procedures undertaken, and their proportion to one another. This is well shown in the figures for one district hospital, with a great reputation for the quality of its care, and which serves a disadvantaged population with poor communications. In one year 2031 babies were born there; 96 of these (about 5%--a good figure to aim for) were delivered by lower segment Caesarean section, none by classical Caesarean section, 55 by vacuum extraction, 16 with forceps (the superintendant is a skilled obstetrician), and 23 by symphysiotomy (the open method). There were 10 destructive operations, and 4 ruptured uteri. There were 6 deaths, only 2 related to delivery. It is difficult to suggest a suitable * target' for maternal mortality, so much depends on the circumstances; ideally, it should be almost zero. 50 per thousand is usually considered a good perinatal mortality for a district hospital in the developing world, and 30 a very good one; ideally, again, it should be much lower than this. The earlier targets in the list below are from among those recommended by W H O after the 1985 conference at Fortazela, Brazil, which was concerned to reverse the trend towards high technology childbirth, and to promote more enlightened methods. TARGETS F O R G O O D OBSTETRICS W H O ' S TARGETS include: The whole community is informed about the various kinds of birth care, so that each mother can choose the kind of birth she wants. There is active collaboration with any traditional birth attendants in the community. A chosen member of the family is present during birth, and during the postnatal period. Immediate breast-feeding is encouraged, even before a mother leaves the delivery room. The Caesarean section rate is in the region of 5 % , and is certainly less than 8%. A further Caesarean section is not automatic after a previous one, and suitable mothers are given a trial of labour. Ligation of the Fallopian tubes is not used an an indication for section. The dorsal lithotomy position is not used routinely during labour and delivery. Walking is encouraged during labour, and each mother decides which position she will adopt during delivery. Labour is induced for specific medical indications only, with an induction rate of 10%. Anaesthetic and analgesic drugs are not given routinely, but only when needed to prevent or treat some complication (this depends on the culture; some rural women are so tough, and put up with so much pain without complaining, that they may need to be encouraged to accept analgesia). The membranes are not ruptured early as a matter of routine. The perineum is protected wherever possible. Episiotomy is done on appropriate indications only, and is not done routinely. OTHER TARGETS. The maternal mortality rate in the hospital and the community (15.1) is known, as is the hospital perinatal mortality rate. Regular perinatal mortality meetings are held. Antenatal cards are issued to all mothers. The blood pressure is measured and recorded at every antenatal visit. A wide range of family-planning methods are available at all M C H clinics, in the hospital and outside. Labour charts, including the cervicograph, are in regular use in the hospital and the clinics. Destructive operations and symphysiotomies are done when necessary.
