It may be that the deeper lymph nodes such as the mediastinal and mesenteric groups may have been involved earlier buy discount tegretol 200 mg on-line spasms when falling asleep. The associated symptoms such as malaise purchase tegretol master card spasms before falling asleep, weight loss and fever are quite characteristic tegretol 100mg visa muscle relaxant cyclobenzaprine high. Pressure effects by enlarged mediastinal lymph nodes such as venous engorgement, cyanosis of the head and neck and difficulty in respiration due to pressure on the bronchus are sometimes the presenting features. Bone pain with vertebral collapse secondary to bony metastasis, though rare, should be kept in mind. Root-pain, and even paraplegia may develop due to pressure on the spinal cord from deposits in the vertebrae or pressure by retroperitoneal nodes on the nerve roots while they come out of the intervertebral foramina. A peculiar feature of this disease is the complaint of enhanced pain at the sites of disease induced by drinking alcohol. The nodes tend to remain discrete moveable with little tendency towards matting and softening. Splenic enlargement is a significant finding of this disease and is found in not less than 75% of the cases. Progressive anaemia is more or less constant and may be due to splenomegaly or bony metastases. Occasionally eosinophilia is associated with megakaryocytosis and increased platelet count. Death may occur within a few weeks or the patient may survive longer without any treatment. All stages are further subdivided on the basis of absence (A) or presence (B) of the following systemic symptoms e. Although painless to start with, continuous pain of varying severity will appear as the growth increases. The involved nodes grow much more rapidly and are less hard than those due to secondary carcinoma. When they break out or are divided after removal, black pigmentation becomes evident. The most important diagnostic feature is marked increase in the number of lymphocytes and their precursors in the blood. Besides trauma, there is only other way of involvement of a peripheral nerve, and that is by infiltration of the nerve by malignant growth. The types of trauma which may injure a peripheral nerve may be a wound — either an incisional cut (e. Incisional wound or the penetrating wound may injure the nerve anywhere in the body but commonly seen at the wrist when the median or the ulnar nerve becomes the victim. Injury to the nerve caused by fracture or dislocation is commonly seen in the arm when the radial nerve is injured by the fractured shaft of the humerus, at the elbow in the supracondylar frac ture of humerus when the median, the ulnar or the radial nerve may be injured. In frac ture of the neck of fibula, the lateral popliteal nerve is often injured. In subcoracoid dislocation of the humerus and fracture of the neck of the humerus, the axillary nerve may be injured leading to paralysis of the deltoid. In posterior dislocation of the hip, subtrochanteric fracture and supra-condylar fracture of the femur, the sciatic nerve may be injured. The most peculiar feature is that generally the common peroneal portion of the sciatic nerve is involved. The upper lesion (Erb-Duchenne) is caused by the injury which causes forcible increase of the angle between the neck and shoulder thus stretching upper trunk of the brachial plexus. This type of injury may occur during difficult labour when a pull on the head of the foetus is made while the shoulder is arrested inside or due to fall of a load on the shoulder. The lower lesion (Klumpke) of a brachial plexus may occur when the arm is being forcibly hyperabducted. Sometimes the patient complains of a constant intense burning pain after an injury even after the wound has healed. This type of pain may commence immediately following the injury or more often after a month or so when the skin wound has healed. In these cases, an enquiry must be made whether an injection has been made in the arm or in the thigh or any site near the nerve lesion. Irritating drug such as quinine when injected intramuscularly in the deltoid or in the thigh may affect the axillary nerve or the sciatic nerve respectively. In these cases enquiry must be made whether the wound was infected or not, as infection will lead to fibrosis and will not allow proper regeneration of the nerve. Wrist drop is seen in paralysis of radial nerve, which sup plies all the extensors of the wrist joint. Foot drop is caused by paralysis of the lateral popliteal nerve which supplies the dorsiflexors and evertors of the foot. This deformity is due to paralysis of the interossei and lumbricals, which are concerned with flexion of the metacarpophalangeal joints and extension of interpha- Fig. The extensor digitorum is mainly concerned with extension of the metacarpophalangeal joints and has little action in extension of the interphalangeal joints. Those muscles being unopposed by the interossei in the metacarpophalangeal joints and the flexors of the fingers act unopposed by Fig. The former deformity is due to paralysis of the opponens pollicis and the latter deformity is due to paralysis of the lateral half of the flexor digito- Fig. In this deformity the arm hangs by the side of the body and internally rotated with forearm extended at the elbow and fully pronated (Fig. Wasting of the deltoid, thenar and hypothenar eminences, hollows between the metacarpals due to atrophy of the interossei should be looked for and when the corresponding nerve is damaged this becomes obvious. Sometimes measurement of the circumference may be required to establish definitely muscular wasting. Vaso-motor changes in the form of pallor, cyanosis, excessive sweating and trophic disturbances such as ridged and brittle nails, scaly skin etc. Presence of scar or wound muscular injection of quinine which has will also give an indication as to which nerve may be affected the axillary nerve. The temperature of the affected limb should always be compared with that of the normal side. This is very important as this will give a clue as to which nerve has been affected. As for example in case of lesion of the axillary nerve (due to dislocation of shoulder or fracture of the neck of the humerus) the deltoid muscle will be paralysed, but cannot be tested as the dislocation or fracture will itself prevent abduction of the shoulder. In this case if the students remember that the axillary nerve is also concerned in supplying cutaneous twigs to the skin over the lower part of the deltoid, that part will automatically be anaesthetised and the diagnosis of injury to the axillary nerve will be established. If the skin of the affected side is seriously palpated an area of hyperaesthesia can be detected which is the site of nerve regeneration. By the shifting of this site of hyperaesthesia one can assess the speed of regeneration of the nerve.
X-ray shows blurred and irregular joint lines with surrounding sclerosis tegretol 400mg with amex spasms 1983 dvd, joint spaces are gradually diminished and may be obliterated purchase 100 mg tegretol free shipping spasms when falling asleep. Degeneration of intervertebral discs produce increasing stoop characteristic of the aged purchase 100mg tegretol overnight delivery muscle relaxant 1. It may be postural as compensatory to fixed flexion deformity or congenital dislocation of the hip. Tuberculosis of the hip and malunited fracture of the femur may lead to this condition. The deformity may also develop to correct the centre of gravity of the body as required in last trimester of the pregnancy, large uterine fibroid or a big fatty abdomen. The pathology lies either in the lamina which may be in two pieces or unduly elongated or in the facets which are poorly developed. The Congenital variety is by far the commoner and constitutes no less than 75% of the cases. Degenerative variety constitutes about 20% of cases and is due to the degenerative changes in the facet joints as also the discs, which permit the forward shift despite intact lamina. Spondylolisthesis is better diagnosed however in oblique view which is shown in the second figure. An outline of a ‘Scot’s terrier’ can easily be seen in this view with the neck formed by the pars interarticularis. When there is a break, as shown by arrow, the terrier is decapitated and the lesion in the pars is seen. In the congenital variety there is developmental defect of the pedicle of the 5th lumbar vertebra. The lower articular processes remain with the sacrum in situ whilst the upper articular processes along with the spinal column above move forward. The main complaint is the backache which becomes more obvious after exercise or strain. The pain may radiate down to the legs and there may be weakness of the lower extremities. This condition may affect any age but degenerative variety is obviously rare before the age of 40 years. On examination the trunk appears shorter, the buttocks look flat, the upper angle of the sacrum forms a distinct prominence on the back with depression just above it. The most important finding on inspection is a transverse furrow encircling the body between the ribs and the iliac crests. On palpation a definite prominence at the upper angle of the sacrum will be obvious when the clinician runs his fingers down along the spinous processes. X-ray shows the upper border of the 5th lumbar vertebra is too low in anteroposterior view, whereas lateral view demonstrates clearly the forward shift of the spinal column, a gap in the lamina, elongated lamina or defective facets if they are present. To demonstrate the gap in the lamina which may not be so obvious in lateral view, oblique views may be required. In prodromal stage, the patient gets tired, there are loss of weight and evening rise of temperature. Deformity in the form of a hump or angular kyphos leading to hunchback is not uncommon. On palpation one can detect localized tenderness if pressed on the particular spine. This becomes obvious in the involvement of the lumbar spine than that of the thoracic spine. X-ray findings are important in which the adjacent bodies will show destruction with diminution of the intervertebral space (cf. From the posterior mediastinum it may gravitate down beneath medial or lateral arcuate ligament to become psoas or lumbar abscess respectively. Paraplegia is quite common due to the fact that the spinal canal is narrowest in the region. There is hardly any collapse of the affected vertebrae owing to early recumbency by the patient, rapid new bone formation and paravertebral calcification. The prognosis is dismal as there always remains the chance for the infection to spread and involve the meninges. In the second figure one can see the normal interverte posterior longitudinal ligament causing bral space. If the tear does not heal properly further prolapse is likely to take place with trivial strain, (ii) Increased tension within the nucleus pulposus is sometimes seen in some physical illnesses and emotional stress. Extra fluid is absorbed, the nucleus swells and may even burst through the annulus. Prolapsed disc may press on the duramater causing backache or on the nerve roots causing backache or sciatica or both. The prolapse of a disc occurs nearly always just above or below the 5th lumbar vertebra (i. Sciatica is at first located in the buttock but it soon spreads to the thigh, leg along the posterior aspect even upto the toes. Subsequent attacks are also sudden in onset but may follow trivial injury such as coughing etc. On examination, the patient is found to stand with a characteristic attitude — lumbar scoliosis with convexity to the affected side, kyphosis and slight flexion of the hips and knees. Lateral flexion on the side of the lesion is also very painful, but rotation may be free and painless. Knee jerk may be diminished (in case of lesion between L3 and L4), but tendo Achillis jerk is almost always absent. Extension of the great toe against resistance will show weakness of the extensor hallucis longus. But after many months or years with subsequent attacks there will be narrowing of the intervertebral space with lipping of the vertebral bodies, i. Epidurography is also helpful so far as the diagnosis of this condition is concerned. Sometimes the disc material may extrude with a pressure of the body and press on the duramater leading to backache. Osteophytes and protruded disc may also press on the nerve roots causing sciatica. There will be lipping at the corners of the vertebral bodies and presence of osteophytes around the interarticular joints. The main features are severe local pain with collapse of the vertebral column with or without symptoms of cord compression. X-ray shows osteolytic changes in the vertebral bodies, barring in case of secondaries from the prostate when the lesion will be osteoblastic. There may be collapse or wedging of the vertebra, but the intervertebral space will remain normal (cf.
Pain independent of micturition is come across in balanoposthitis discount tegretol 200 mg overnight delivery spasms right abdomen, herpes purchase 400 mg tegretol visa spasms vhs, advanced carcinoma of penis etc purchase tegretol with a visa muscle relaxant medication. When the prepuce becomes tight round the corona with swelling of the glans, the condition is known as paraphimosis. This is mainly a congenital deformity but acquired type may be seen following a meatal ulcer. An ulcer may be due to either Hunterian chancre or chancroid or granulomatous inguinale or an epithelioma. A Hunterian chancre is painless with the well- defined edge and an indurated base. Chancroid (soft sores) are multiple, painful ulcers with ill- defined and oedematous margins discharging pus. Two types are usually seen — a papilliferous tumour (cauliflower-like growth) and an ulcer with raised and everted edge and necrotic floor. Venereal warts are multiple papillomatous growths which are moist and discharge bad smelling serous fluid. Balanitis is an infection of the glans penis and posthitis is infection of the inner surface of the prepuce. The patient complains of a bad smelling creamy discharge from beneath the prepuce. Epispadias is a condition in which the urethral opening is on the dorsal surface of the penis. But more common hypospadias is a condition in which the urethra opens on the ventral surface of the penis. According to the position of the opening it is classified into a glandular type (opening is on the glans), a penile type (opening is on the body of the penis) or the perineal type (the opening is on the Watch the patient passing urine. Body of the penis is palpated with index finger and thumb of both hands systematically. If urethritis is suspected the penis can be milked with the thumb and the index finger to express some purulent discharge. But it must be remembered that enlargement of these lymph nodes do not always signify the presence of metastasis. In fact, in about 50% of cases swelling of these lymph nodes is due to inflammation rather than lymphatic metastasis. Involvement of the urethra by inflammation or neoplasm will lead to enlargement of lymph nodes of Fig. The external urinary meatus is not situated at the tip of the penis, but at some point on the under-surface of the penis or in the perineum. According to its location, hypospadias can be of the following types — (a) Glandular type in which the meatus is situated on the under-surface of the glans generally at a point where the frenum (which is absent) is normally attached. This is the most common variety, (b) Coronal type, in which the meatus is at the corona, (c) Penile type, in which the meatus is situated at some point on the under-surface of the body of the penis between the glans and the penoscrotal junction, (d) Penoscrotal type, in which the meatus is at the penoscrotal junction, (e) Perineal type, in which the meatus is at the perineum about 3 cm in front of the anus. In all varieties the penis is curved downwards (chordee) (except the glandular type) due to presence of fibrous tissue from the meatus to the tip of the penis. Three varieties are usually seen — (a) Glandular type, where the meatus is situated on the dorsal aspect of the glans. The penis curves upward, (c) Total type, which is associated with ectopia vesicae and incontinence of urine. Recurrent balanoposthitis causing pain and purulent discharge are the common complications. Phimosis may develop in adults (acquired type) from long standing balanoposthitis or carcinoma occurring on the undersurface of the prepuce. So in case of phimosis in the adult it is better to make a dorsal slit for proper examination inside. The patient complains of obnoxious smell and creamy discharge from beneath the prepuce. When the foreskin is retracted one will find red and oedematous inner surface of the prepuce. If the retraction is not possible a dorsal slit or circumcision must be performed. Patient usually complains of itching, pain or discharge from the subprepucial space. If the prepuce can be retracted, the glans and inside of the prepuce should be examined properly. The main causes are — (i) Candida albicans is common in sexually active persons and diabetes. This condition should not be ignored as a sub-prepucial carcinoma may be the cause of this condition. Openings are not usually seen except when the follicles become infected often as a complication of urethritis, when pus will be seen extruding through the prominent openings. These glands are situated on either side of frenum and the ducts open in the prepucial sac and not in the urethra. These glands become infected as complication of gonococcal urethritis and give rise to firm, tender swellings on the undersurface of the glans just lateral to the frenum. It is characterised by alternating open ulceration which may slightly bleed to stain the undercloth and scabbing of the meatus leading to narrowing of the external meatus. If untreated it may lead to pin-hole meatus which causes retention of urine to varying extent. It occurs in the primary stage of syphilis and the incubation period is 3-4 weeks from the exposure. It is a painless ulcer with well-defined margin raised above the surface with indurated base. Spirochaeta pallida can be demonstrated in the serous discharge on dark-ground illumination. The second stage of syphilis will begin 4-6 weeks after the appearance of the chancre. The inguinal lymph nodes are invariably enlarged and they show tendency towards suppuration. The infection is caused by a virus of the psittacosis lymphogranuloma inguinale group. The patients mainly present with the secondary lesions, the incubation period of which varies from three to six weeks after exposure. In case of females an additional complication arises if the primary lesion affects the posterior vaginal wall or cervix. Due to intense para-rectal inflammation fibrosis of the rectal wall follows with the formation of a stricture of rectum. Due to lymphatic obstruction there may be occasional elephantiasis of the scrotum and penis as well as the vulva. Ischiorectal abscess, rectovaginal fistulae and perianal abscess may develop in females consequent upon intense para-rectal inflammation. This condition is caused by Donovan body, which is seen as a Gram-negative rod in the cytoplasm of mononuclear tissue cells.
Such radical excision means excision of the rectum with its sheath alongwith all nodes lying on the wall with 5 cm normal tissue above and below the growth and all involved regional lymph nodes buy discount tegretol 100mg on-line muscle relaxant overdose treatment. Obviously if the main nodes are involved the only way to do radical surgery is to ligate inferior mesenteric artery at its origin from the aorta (flush ligation) purchase tegretol 400 mg fast delivery xanax muscle relaxant dosage. So the surgeon usually prefers to ligate inferior mesenteric artery below the origin of 1 or 2 branches buy cheapest tegretol muscle relaxant while breastfeeding. The type of resection which should be employed in a particular case depends on the situation of the carcinoma. For this, rectum has been divided into three parts, (a) The proximal third extends from the junction with the sigmoid colon which is 15 or 16 cm above the anus down to about 11 cm. Temporary proximal defunctioning colostomy may be advisable to secure anastomosis. In young subjects in whom cancers grow rapidly, probably it will be better to do abdomino-perineal resection instead of anterior resection to avoid recurrence. In these cases (i) abdomino perineal resection will be the safest, (ii) If the permanent colostomy has to be avoided one may perform abdomino-perineal pull through operation and making the anastomosis outside the anus to avoid the problem of doing an anastomosis deep in the pelvis. The principal drawback is that some patients do not regain faecal continence, (iii) There is now available a stapling instrument, die E. This has made it technically possible to resect midrectal carcinomas down to the distal limit and to restore continuity by a safe end-to-end anastomosis. This is usually achieved by a combination of mechanical cleansing and anti biotic treatment. The mechanical cleansing is per formed by purgatives, enemas or whole-gut irriga tion. Nowadays cefuroxime 750 mg plus metronidazole 500 mg are given 1 hour before surgery. Two further doses are given of the same drugs at 6 and 12 hours after the operation. If the carcinoma is obstructive it is preferable to do a temporary colostomy a few days before the opera tion to do proper cleansing of colon on both sides of colostomy. In case surgery is necessary immediately, perioperative washout of the loaded colon is Fig. An indwelling catheter is introduced into the bladder before the patient is sent to the operation theatre. In his original description, one surgeon operates the abdominal part and then he moves to the lower end of the table and performs the perineal part. But in 1938, Lloyd-Davies advocated the synchronised operation, in which one surgeon does the abdominal part of the operation, while the other surgeon performs the perineal part simultaneously. This is widely prac tised nowadays for the simple reason that it saves lot of time and causes much less shock to the patient. Essentially, the bowel with the growth along with surrounding healthy tissue and involved lymph nodes are removed. To do this, the following structures should be removed: (i) The anal canal, external sphincter muscle with a wide area of the perianal skin, (ii) the whole of the rectum with its surrounding fasciae and epi- and pararectal groups of lymph nodes, (iii) adjoining part of the pelvic floor and peritoneum and (iv) three quarters of the pelvic colon along with its lymph nodes at the mesocolon. The left wall of the wound is retracted and the adhesions between the sigmoid colon and the posterior abdomi nal wall are divided. The descending colon is pulled to the right and the peritoneum at its lateral border is cut from the splenic flexure to the sigmoid colon. The left of the pelvic mesocolon is incised well clear off any malignant infiltration. That means the lymph nodes in the sigmoid mesocolon and by the sides of the inferior mesenteric artery are studied. If the glands are found to be involved around the origin of the inferior mesenteric artery, the artery should be tied and divided flush with the aorta. From this point of division of the main vessels, the peritoneum is incised vertically downwards to reach the right side of the rectum. This incision is carried forwards over the front of the rectum to join the incision down to the left side of the rectum. By gentle dissection with the fingers, the rectum is gradually freed posteriorly as far down as the sacrococcygeal joint, where it meets the perineal operator, who by this time has excised the last piece of the coccyx. While doing this, one has to incise the fascia of Waldeyer a little away from the rectum. The rectum is now pushed backwards into the hollow of the sacrum and dissection started at the plane of cleavage lying between the rectum and the base of the bladder until it reaches the seminal vesicles. The rectum is separated from the seminal vesicles and from the prostate gland, care being taken not to injure the vas deferens. As the rectum is freed anteriorly and posteriorly, it is now attached to the sides with the lateral ligaments. The lower ends of the ureters are defined and their relations with the lateral ligaments of the rectum are assessed. The rectum is drawn over to one side putting the opposite lateral ligament under stretch. As the main artery has already been ligated, the ischaemic areas will become obvious. The distal end is covered with a sterile glove, so that it can be taken out easily through the perineal wound. The edges of the peritoneum are picked up, mobilised and sutured with interrupted sutures. It may be sutured with continuous catgut suture, but the ureter must be protected. The external oblique aponeurosis is incised in a cruciate manner and the underly ing muscles are split along the line of the fibres. The peritoneal space lateral to the colostomy bowel is closed by continuous or interrupted sutures to prevent internal herniation at a later stage. Extraperitoneal method (Goligher) — is sometimes practised to bring the cut-end of the colon for colostomy extraperitoneally. For this the lateral cut-edge of the peritoneum is picked up and a tunnel behind the peritoneum is made for the colon to pass through. This obviates the necessity to close the peritoneal gap on the lateral side of the colon. The end of the protruding colon, which has been crushed by the crushing clamp is cut off. The mucous membrane of the bowel is now sutured to the skin edge with interrupted chromic catgut sutures. A dry swab is inserted into the anal orifice and the anus is closed by a stout purse-string suture introduced subcutaneously. The posterior end of this incision is carried more posteri orly to one or other side of the midline as far as the middle of the sacrum.
The peripheral nerves are very sensitive to ischaemia and this leads to pain buy tegretol australia spasms from overdosing, paraesthesia and paralysis buy genuine tegretol line spasms toddler, (B) Arterial trauma may also cause acute arterial occlusion purchase tegretol without prescription muscle relaxant antagonist. The causes of arterial trauma are:— (a) Most arterial injuries result from penetrating wounds which partly or completely disrupt the walls of the arteries, (b) Pressure on a major artery by an angulated bone, (c) Intimal rupture of a major artery due to fracture or dislocation, (d) Injury to a major artery by a bone fragment. Followings are the fractures and dislocations which may cause acute arterial occlusion — (i) Supracondylar fracture of humerus; (ii) Supracondylar fracture of femur; (iii) Dislocated shoulder; (iv) Dislocated elbow; (v) Dislocated knee. Commonly acute thrombosis occurs in an artery considerably narrowed by arterial disease. Moreover acute-on-chronic arterial thrombosis may occur in which case acute conditions develop on already existing chronic occlusion. Pain in the limb is the most important and initial symptom which affects the limb distal to the acute arterial occlusion. There may be calf tenderness or pain on dorsiflexion of foot in an otherwise anaesthetic limb. In majority of cases there may be some sensory disturbances only, which vary from paraesthesia to anaesthesia. In aortic embolism, pain is felt in both the lower limbs, there is also loss of movements of hips and knees. Coldness and numbness and change of colour affect the inferior extremities below the hip joints or midthighs. In popliteal embolism, there is pain in the lower leg and foot, there is loss of movement of the toes. Numbness, coldness and change of colour are noticed in the hands and distal forearm. Though angiography is quite helpful in diagnosing the case it may delay operation. Broadly, an aneurysm can be classified into 3 types — (a) True aneurysm, (b) False aneurysm and (c) Arteriovenous aneurysm. A true aneurysm, according to shape, may be fusiform, saccular or dissecting aneurysm. An aneurysm can occur in any artery, though abdominal aorta, femoral and popliteal arteries are more commonly affected. However splenic, renal and carotid arteries have also undergone aneurysmal changes. Traumatic may be due to (i) direct trauma such as penetrating wounds to the artery, (ii) Irradiation aneurysm, (iii) Arteriovenous aneurysm from trauma, (iv) Indirect trauma may cause aneurysm e. Degenerative is by far the most common group and (i) atherosclerosis is the commonest cause of aneurysm, (ii) A peculiar aneurysm of the abdominal aorta is noticed in young South African Negroes which is due to intimomedial mucoid degeneration. Sometimes arteriography cannot diagnose an aneurysm as such thrombosis does not show dilated sac in arteriography. Thrombosis and emboli formation — leads to circulatory insufficiency of the inferior extremity. Infection — may occur from organisms in the blood and signs of inflammation become evident. Spontaneous cure — occasionally occurs particularly in saccular aneurysm due to gradual formation of clot. Arteriography is the main diagnostic tool, though sometimes it cannot reveal dilatation of the artery due to presence of laminated thrombus inside the arterial sac. There is increased temperature of the skin with port-wine discolouration due to increased collateral circulation. Increased length of the limb is noticed particularly when the fistula is congenital. Pressure on the artery on the proximal of the fistula causes diminution of the swelling. Even indolent ulcer may be noticed — this is due to inadequate arterial supply below the fistula due to diversion of blood into the veins. There are various places in the body where veins show tendency towards varicosity e. So far as the aetiology is concerned varicose veins mostly occur due to incompetence of their valves. It is not found in other animals and seems to be a part of penalty of erect posture which the human beings have adopted. These are tone and contractility of the muscles of the lower limb being encircled by a tough deep fascia. Incompetence of valves, which may be a sequel of venous thrombosis, seems to be the most important factor in initiating this condition. Varicosity may also be secondary, predisposed by any obstruction which hampers venous return e. In younger age group congenital arteriovenous fistula may be the cause of varicose vein. Varicose veins may also occur in individuals involved in excessive muscular contractions e. It is doubtful if these occupations cause the varicose veins or they just exacerbate the symptoms already present. The pain gets worse when the patient stands up for a long time and is relieved when he lies down. One thing the student must always remember that it is not the varicose veins which produce the symptoms, but it is the disordered psychology which is the root of all evils. So it is not impossible to come across asymptomatic varicose veins on one side and severe symptoms with very few visible varicose veins on the other side. Patient may complain of bursting pain while walking, which indicates deep vein thrombosis. The ankle may swell towards the end of the day and the skin of the leg may be itching. If the patient is suffering from constipation or a swelling in the abdomen, it may be a cause of secondary varicose vein. Any serious illness or previous complicated operation may cause deep vein thrombosis which is the cause of varicose vein now. If the patient had contraceptive pills for quite a long time, as this may cause deep vein thrombosis. In case of the former a large venous trunk is seen on the medial side of the leg starting from in front of the medial malleolus to the medial side of the knee and along the medial side of the thigh upwards to the saphenous opening. In case of short saphenous vein varicosity the dilated venous trunk is seen in the leg from behind the lateral malleolus upwards in the posterior aspect of the leg and ends in the popliteal fossa. Localized swelling may also be due to superficial thrombophlebitis, (b) Generalized swelling of the leg is mostly due to deep vein thrombosis. More important for this chapter is when the skin of the limb becomes congested and blue due to deep vein thrombosis and this condition is called phlegmasia cerulea dolens. In such severe venous obstruction the arterial pulses may gradually disappear and venous gangrene may ensue.
A few symptoms and signs usually accompany heavy blood loss buy tegretol online spasms in chest, be it internal or external purchase 400 mg tegretol otc knee spasms causes. Increased pulse rate buy online tegretol muscle relaxant back pain, low blood pressure, increasing pallor, restlessness and deep sighing respiration (air hunger) are the typical features of acute blood loss. Cold and clammy extremities, empty veins are also characteristically seen when the bleeding is continuing. Pulse rate and blood pressure should be measured l/4th or 1/2 hourly intervals when the patient is losing blood during his stay in the emergency department. Though fall of blood pressure is often noticed in case of haemorrhage, yet a normal blood pressure cannot exclude the diagnosis of haemorrhage. Often the blood pressure is maintained at normal level by peripheral vasoconstriction due to adrenergic release when the patient is still bleeding. Suddenly the blood pressure may fall abruptly with collapse and even death of the patient. Whatever methods are adopted to measure blood loss, they do not give the actual figure. The blood loss detected by the methods is usually less than the actual loss, because a considerable amount of plasma is lost into the interstitial tissues and a considerable amount of water is lost via lungs, from the wound and by evaporation of sweat from the skin. This loss of plasma and water constitutes approximately 20% more than the blood loss detected by various methods. The other methods are measurement of swelling in case of bleeding from fractures and measurement of blood clot in haemorrhage. The swabs are weighed before they are used and they are weighed again after they are soaked with blood and thrown individually into a collecting basket. As mentioned earlier it cannot give the actual amount of blood loss and it should be multiplied by a factor of 1 Vi in case of moderate operations like partial gastrectomy or radical mastectomy. In moderate swelling in case of fractured shaft of femur, the estimated blood loss is about 1,000 to 2,000 ml. Firstly the plasma volume or the red cells volume is measured and from the haematocrit value the total blood volume can be determined. That means in case of an adult of normal structure the normal blood volume is about 5 to 6 litres. It is only lowered after a few hours by haemodilution caused by movement of extracellular fluid into the vascular space due to natural attempt to restore blood volume. To restore blood volume by blood transfusion, infusion of crystalloid solution and infusion of plasma or plasma substitutes. Morphine is a good sedative and is often used intravenously in the dose of l/4th gr. Due to vasoconstriction of the subcutaneous vessels following haemorrhage absorption of the drug will be minimal. As the effect of the drug is not properly achieved, the surgeon may push some more amount subcutaneously. When the blood volume is restored and the circulation improves, vasoconstriction diminishes and excessive amount of morphine will be absorbed. Morphine however is contraindicated when there is respiratory depression in head injuries, where chloralhydrate is more preferred. In case of haemorrhage from thyroidectomy wound, the head end of the bed should be raised (anti-Trendelenburg position). In case of haemorrhage from varicose vein, the footend of the bed is raised (Trendelenburg position), in this case gravity reduces bleeding. Trendelenburg position is also helpful as it increases blood supply to the brain and helps to restore blood pressure. Sterile pieces of gauze and bandage may be used as pressure bandage to reduce bleeding from external wound. If sterile gauzes and bandages are not available clean linen cloth may be used as bandage to reduce bleeding from the wound. This in fact cannot stop arterial bleeding, on the contrary causes venous congestion and increases venous bleeding. In modern surgery place of tourniquet is only restricted in the operation theatre for use in certain operations as prophylactic measure to control haemorrhage. The distal spirals of the Esmarch bandage are now unwound to expose the site for operation. Before deflating the cuff a firm bandage is applied on the operating wound, so that haemorrhage from minute vessels are stopped by the pressure bandage. Now the bleeding vessel is either ligated with catgut or silk according to the size of the vessel. In case of big vessels like renal artery and vein transfixion suture may be used with silk. When haemorrhage is in the form of oozing, Oxycel or gelatine sponge may be used to stop such bleeding. This type of material provides a network upon which fibrin and platelets are deposited to stop bleeding. Such bleeding can also be stopped by gauze soaked in adrenalin solution (1 : 1000). When the actual bleeding vessel cannot be detected, it is customary to use rolls of gauze for packing the wound for sometime. After 5 minutes the gauze pack is removed and slight bleeding from the spurting vessel can be identified. If a solid viscus is ruptured and bleeds heavily, the whole or part of such viscus should be excised e. These bleedings are small in quantity and continue for quite a long time till effective treatment is performed. In these cases the blood volume is never diminished as plasma replacement occurs as bleeding continues. Red cell replacement however lags behind, which results in microcytic hypochromic anaemia. As the blood volume is normal or slightly more than normal, these patients often develop high-output cardiac failure. If acute haemorrhage occurs in these cases, it is more dangerous than normal individuals as oxygen carriage is already depleted due to low R. When these cases are treated, packed cells should be used instead of whole blood to reduce extra burden on the heart. As soon as haemorrhage takes place, every effort should be made to restore blood volume by blood transfusion. Only when blood is not available for the time being plasma or plasma substitutes may be used. The first step in achieving haemostasis is due to local release of a humoral agent, known as thromboxane. This agent is a powerful constrictor of smooth muscle and promotes aggregation of platelets. It is probably released by the platelets at the site of disruption of the endothelial surface.