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THE TREATMENT OF VARICOSE VEINS: A NEW OPERATION.
239 of the new law. As the Bill appears to be pure consolidation and not to include any proposals for amendment, its passage through Parliament should be the easier. In introducing it into the House of Lords on July 26th the Earl of Onslow stated that, as soon as the Bill was passed, the consolidation of all statutory regulations on the subject would be undertaken. He also announced that a consolidation of the Housing Acts was intended. Meanwhile it is to be hoped that the Public Health Acts are not being forgotten. Their confusion is greater than that of the Health Insurance Acts, and they had a prior claim to be considered for consolidation.
the
corresponding provisions
new
____
THE TREATMENT OF VARICOSE VEINS: A NEW
OPERATION. VARICOSE veins, as is well known, occur in all classes, affecting both men and women, and in those following both sedentary and active occupations. Mr. Philip Turnerpoints out that while it is generally agreed that
creased by the weight of the column of blood, affects first of all the vein and its tributaries below the knee. Another possible cause of obstruction at the termination of the saphenous vein are its tributariesthe superficial epigastric, the superficial circumflex iliac, and the external pudic vein-which are often surprisingly large, and the flow from them being from above downwards is in direct opposition to the flow of blood in the internal saphenous. This opposition to the return of blood in the internal saphenous, though probably trivial in the sitting or recumbent positions, mav be of considerable importance in the erect position with a tense fascia lata and margin of the saphenous
opening.
Mr. Turner suggests that in the operative treatment of varicose veins it is a wrong principle to excise or obliterate the main trunks of venous return, especially the chief of these, the internal saphenous. If the main trunk is removed a great strain must of necessity be thrown upon the smaller and less important vessels, with the result that they dilate and become varicose. The plan adopted by him is the excision of any large varicose veins. In those cases where it is considered that the varicosity is caused by obstruction at the saphenous opening he also divides the fascia lata from the saphenous opening downwards and transplants the long saphenous vein beneath the fascia, which is then sutured over it : at the same time the tributaries which join the internal saphenous at its termination are divided and ligatured. He does not suggest that this operation should be performed indiscriminately ; on the contrary, a careful selection of cases must be made. But in a young or healthy middleaged person, where other causes are absent, where the saphenous vein is thickened and dilated but not tortuous and varicose, where the varicosity affects the lower part of the internal saphenous and its tributaries, but where the small venous radicles are not involved, success may be expected. Mr. Turner has performed this operation, of which he gives full technical details, some 20 times during the past four years, and the results have been so encouraging that he intends to continue this method of treatment.
the essential factor is an increase of pressure in the veins, it must be admitted that in the greater number of cases presenting themselves for treatment no definite cause for the increase in pressure in the veins and no obvious cause for impeding the circulation can be shown. He offers an ingenious suggestion as to the cause of the obstruction to the return of blood in cases where it is not obvious, and describes a method of operative treatment which he has found successful. He believes that in a considerable proportion of cases of varicose veins, especially in those where the patient follows an occupation requiring prolonged ! standing, the real cause of the trouble is an to the flow of blood where the internal saphenous near its termination passes through the saphenous opening, leaving the subcutaneous tissues to join more deeply placed and better supported femoral He recalls the anatomy of the saphenous opening bounded on the outer side by the iliac portion of the fascia lata which has a sharp well-defined edge known The upper wall of this (the as the falciform border. superior cornu) turns inwards superficial to the femoral sheath to join Poupart’s ligament. The lower portion, THE SOCIAL WELFARE OF THE INSANE. known as the inferior cornu, curves inwards, deep to the termination of the internal saphenous vein but IN a pamphlet printed in aid of the Society of the superficial to the femoral sheath, to become continuous Crown of Our Lord Dr. J. R. Lord has dealt with the with the pubic portion of the fascia lata which covers of the social welfare of the patient in a mental the pectineus and adductor longus muscles, and is problem that the time has come to revise believing hospital, attached to the ilio-pectineal line of the pubis. Though of seclusion the attitude resulting from the cloudiness there is no sharp alteration in direction, the internal mediaeval thought which still darkens the public of vein here the crosses well-defined inferior saphenous outlook in this connexion. Recalling the state of cornu of the falciform edge and joins the femoral vein affairs before 1766, when " the doors of Bethlem were on a deeper plane, the sharp fascial margin intervening the faces of curiosity and wanbetween the two vessels. This is a relationship where, finally slammed in Dr. Lord states that " one has only to call to tonness," to Mr. some factor Turner, according may easily pro- mind the disgraceful scenes which often characterise duce a slight but definite degree of obstruction, the admission of the public to the hearing of sensaor over long periods, !, tional divorce or murder cases to be reminded that acting continuously intermittently may produce far-reaching results. This additional there is a section of the public whose appetite for the factor is, he suggests, increase in the tension of the ’, morbid and is insatiable, and there is not unsavoury the In or recumbent fascia lata. the sitting position a doubt that the mental hospitals have had good fascia lata is relaxed ; in the erect position, on the for their attitude to publicity." This other hand, the fascia lata is tense, and so also must grounds has helped to maintain the conattitude, however, be the sharp falciform edge with its superior and of public ignorance as to what insanity really inferior cornua, the latter between the superficial and tinuity although to say that the insane are treated " behind deep venous trunks. The obstruction need not be is, a shut door " is misleading. Dr. Lord points out that complete : a slight degree of interference acting over there must be at least 20,000 people employed in a long time will be quite sufficient to overfill the veins, mental hospitals, that about 10,000 patients pass to cause them to dilate, and eventually to become the hospitals each year, and that anyone who varicose. After a time the weakest valves will become through the name of a can gain admission on gives incompetent, and then the effect of the increased visiting days ; thus patient it would be difficult to keep be more in the will felt still veins lower pressure down in the leg. The localised swelling occasionally anything secret save those personal details which are guarded as a matter of course. Nevertheless, the seen and known as a saphenous varix Mr. Turner attributes to a localisation of the trouble bv a atmosphere of isolation persists, with detriment to the of psychological medicine, and Dr. Lord particularly competent set of valves which protects progress have the life of the outside community brought would the distal portion. More generally the valves become incompetent, and the back-pressure, in1 Social Workers and the Insane. An address delivered
obstruction j
vein
the
vein.
____
which,
1 Guy’s Hospital Reports. London: Henry Frowde Hodder and Stoughton. Vol. III. Fourth Series. No. 2.
and
before the Society of the Crown of Our Lord in London London: Adlard and Son and West 1923. on May 3rd, Newman, Ltd. 6d.
the
corresponding provisions
new
____
THE TREATMENT OF VARICOSE VEINS: A NEW
OPERATION. VARICOSE veins, as is well known, occur in all classes, affecting both men and women, and in those following both sedentary and active occupations. Mr. Philip Turnerpoints out that while it is generally agreed that
creased by the weight of the column of blood, affects first of all the vein and its tributaries below the knee. Another possible cause of obstruction at the termination of the saphenous vein are its tributariesthe superficial epigastric, the superficial circumflex iliac, and the external pudic vein-which are often surprisingly large, and the flow from them being from above downwards is in direct opposition to the flow of blood in the internal saphenous. This opposition to the return of blood in the internal saphenous, though probably trivial in the sitting or recumbent positions, mav be of considerable importance in the erect position with a tense fascia lata and margin of the saphenous
opening.
Mr. Turner suggests that in the operative treatment of varicose veins it is a wrong principle to excise or obliterate the main trunks of venous return, especially the chief of these, the internal saphenous. If the main trunk is removed a great strain must of necessity be thrown upon the smaller and less important vessels, with the result that they dilate and become varicose. The plan adopted by him is the excision of any large varicose veins. In those cases where it is considered that the varicosity is caused by obstruction at the saphenous opening he also divides the fascia lata from the saphenous opening downwards and transplants the long saphenous vein beneath the fascia, which is then sutured over it : at the same time the tributaries which join the internal saphenous at its termination are divided and ligatured. He does not suggest that this operation should be performed indiscriminately ; on the contrary, a careful selection of cases must be made. But in a young or healthy middleaged person, where other causes are absent, where the saphenous vein is thickened and dilated but not tortuous and varicose, where the varicosity affects the lower part of the internal saphenous and its tributaries, but where the small venous radicles are not involved, success may be expected. Mr. Turner has performed this operation, of which he gives full technical details, some 20 times during the past four years, and the results have been so encouraging that he intends to continue this method of treatment.
the essential factor is an increase of pressure in the veins, it must be admitted that in the greater number of cases presenting themselves for treatment no definite cause for the increase in pressure in the veins and no obvious cause for impeding the circulation can be shown. He offers an ingenious suggestion as to the cause of the obstruction to the return of blood in cases where it is not obvious, and describes a method of operative treatment which he has found successful. He believes that in a considerable proportion of cases of varicose veins, especially in those where the patient follows an occupation requiring prolonged ! standing, the real cause of the trouble is an to the flow of blood where the internal saphenous near its termination passes through the saphenous opening, leaving the subcutaneous tissues to join more deeply placed and better supported femoral He recalls the anatomy of the saphenous opening bounded on the outer side by the iliac portion of the fascia lata which has a sharp well-defined edge known The upper wall of this (the as the falciform border. superior cornu) turns inwards superficial to the femoral sheath to join Poupart’s ligament. The lower portion, THE SOCIAL WELFARE OF THE INSANE. known as the inferior cornu, curves inwards, deep to the termination of the internal saphenous vein but IN a pamphlet printed in aid of the Society of the superficial to the femoral sheath, to become continuous Crown of Our Lord Dr. J. R. Lord has dealt with the with the pubic portion of the fascia lata which covers of the social welfare of the patient in a mental the pectineus and adductor longus muscles, and is problem that the time has come to revise believing hospital, attached to the ilio-pectineal line of the pubis. Though of seclusion the attitude resulting from the cloudiness there is no sharp alteration in direction, the internal mediaeval thought which still darkens the public of vein here the crosses well-defined inferior saphenous outlook in this connexion. Recalling the state of cornu of the falciform edge and joins the femoral vein affairs before 1766, when " the doors of Bethlem were on a deeper plane, the sharp fascial margin intervening the faces of curiosity and wanbetween the two vessels. This is a relationship where, finally slammed in Dr. Lord states that " one has only to call to tonness," to Mr. some factor Turner, according may easily pro- mind the disgraceful scenes which often characterise duce a slight but definite degree of obstruction, the admission of the public to the hearing of sensaor over long periods, !, tional divorce or murder cases to be reminded that acting continuously intermittently may produce far-reaching results. This additional there is a section of the public whose appetite for the factor is, he suggests, increase in the tension of the ’, morbid and is insatiable, and there is not unsavoury the In or recumbent fascia lata. the sitting position a doubt that the mental hospitals have had good fascia lata is relaxed ; in the erect position, on the for their attitude to publicity." This other hand, the fascia lata is tense, and so also must grounds has helped to maintain the conattitude, however, be the sharp falciform edge with its superior and of public ignorance as to what insanity really inferior cornua, the latter between the superficial and tinuity although to say that the insane are treated " behind deep venous trunks. The obstruction need not be is, a shut door " is misleading. Dr. Lord points out that complete : a slight degree of interference acting over there must be at least 20,000 people employed in a long time will be quite sufficient to overfill the veins, mental hospitals, that about 10,000 patients pass to cause them to dilate, and eventually to become the hospitals each year, and that anyone who varicose. After a time the weakest valves will become through the name of a can gain admission on gives incompetent, and then the effect of the increased visiting days ; thus patient it would be difficult to keep be more in the will felt still veins lower pressure down in the leg. The localised swelling occasionally anything secret save those personal details which are guarded as a matter of course. Nevertheless, the seen and known as a saphenous varix Mr. Turner attributes to a localisation of the trouble bv a atmosphere of isolation persists, with detriment to the of psychological medicine, and Dr. Lord particularly competent set of valves which protects progress have the life of the outside community brought would the distal portion. More generally the valves become incompetent, and the back-pressure, in1 Social Workers and the Insane. An address delivered
obstruction j
vein
the
vein.
____
which,
1 Guy’s Hospital Reports. London: Henry Frowde Hodder and Stoughton. Vol. III. Fourth Series. No. 2.
and
before the Society of the Crown of Our Lord in London London: Adlard and Son and West 1923. on May 3rd, Newman, Ltd. 6d.