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ClinicalLecture ON THE TREATMENT OF VARICOSE VEINS.
of the vein above the knee, I have observed that the vessel is frequently curved into a. large circle of irregular form, situated about half-way along the inner side of the thigh, and here the vessel is always very large. This morbid condition of the superficial vein owes its existence to a 1’emora in the venous circulation, due to a want of power, situated somewhere, in the entire system of which it forms a part; and as the heart forms the centre of this system, and claims so large a share of the propelling power of the blood, so it appears but reasonable to refer to this organ the main, if not the exclusive, seat of the evil. It appears also reasonable to infer that, the propelling power from behind being imperfect, and the transmission of venous blood into the large vessels of the trunk being consequently more or less retarded, the weight of a large and long column of blood, equal, perhaps, to that of eighteen inches, must effect, in some manner, not only the course, but the structure, of the veins below; and thus we find them diverted from their original track, distorted in form, dilated in calibre, and greatly thickened in the texture of their coats. Coupled with this local condition of the veins, you will not be surprised if I tell you that the heart in persons so affected beats languidly, and that the vigour of the system is invariably at a low ebb. It is of importance that you observe this condition of the system, lest, in your endeavour to remedy an evil, in the strucyou lose sight of the cause on which the change ture and course of the vessels is originally based, and you resort to an agent which, however efficient it may prove in the abatement of the evil, cannot entirely eradicate it. Varicose veins of the leg may exist to a large extent without occasioningany great degree of inconvenience or pain, but this is rather the exception to the rule; usually they are a source of great discomfort, and often of actual suffering. Persons so affected are debarred from active exercise, whether on foot or on horseback. The disease falls hardest on the labouring classes, in which indeed it is more commonly found, and in the severity of the suffering is so great as to preclude
portion
Clinical Lecture ON THE
TREATMENT OF VARICOSE VEINS. Delivered at St. Bartholomew’s
BY FREDERIC C. SURGEON TO
Hospital,
Feb. 1st, 1856.
SKEY, ESQ., F.R.S., THE HOSPITAL.
GENTLEMEN,ňAmongst the diseases of minor importance, frequent occurrence of which occasions a very large aggregate of discomfort, and, indeed, of suffering, may be classed
the
that of varicose veins. This abnormal condition of the venous tubes occupies the superficial veins of the lower extremity for the most part, but it may prevail extensively throughout the surface veins of the entire system. Some years ago I was consulted by a gentleman of about twenty-two years of age, each of whose extremities exhibited on its surface very remarkable congeries of veins, all in a varicose state, from the dorsal vessels of the hand to the summit of the cephalic, and throughout the entire length of the saphenae of the legs, both major and minor. As a general rule, however, the disease is confined to the saphena major of one or both lower extremities, being commonly limited to the vessel below the knee, though often extending above it. Under some circumstances, the ramifications, or rather the contorted trunk of the saphena, acquires a great magnitude, being in parts of its course equal to that of the index fiuger. When the disease occupies any
334
which
their devotion to their daily occupation. It is the occasional cause of a still greater evil: the smaller venous capillaries about the ancle, on which the brunt of the increased weight falls, become dilated, and the skin in that region is converted into a large discoloured patch of purple hue, into which one or
will
pints, and I need not tell you that this is an evil of no slight magnitude. Various have been the modes, and no less the degree of success, attending the treatment of this disagreeable Some twenty-five years ago, varicose veins were disease. largely experimented on in the various metropolitan hospitals of that day. The veins were divided, some directly, some subcutaneously; some were tied in one or more places, and some were laid open longitudinally with the lancet. The result of these experiments, performed, as I recollect, by surgeons of experience andjudgment, was, however, by no means satisfactory, and death resulted on more than one or two occasions
likely to be
promote healthy vital actions, such as bark, opium, iron, wine, brandy, and animal food. If your patient’s bowels become constipated, remove their contents by a mild laxative; but as a general, almost a universal rule, leave the ’’I secretions" to take care of themselves. Indeed, I will venture to more of the larger vessels may be traced, often grooving the say that I deem it of so much importance to retain in the alisurface of the bone. This discoloured patch has a tendency to mentary canal all the nourishment that is attainable from the advance into the state of chronic inflammation, in which the food, that I would suggest, should you adopt the opinion that larger vessel ulcerates, and a large quantity of blood may man cannot enjoy health without the frequent employment of escape from the vessel before any rational attempt is resorted purgative medicine, that you had better leave varicose veins and to to arrest it. I calculated the quantity of blood lost by a their treatment to your neighbour. As a general rule, you may patient under these circumstances at between two and three rely upon it that the actions of a man’s bowels are far more diurnal and
regular on a full
diet than
on a
limited
one.
In the month of July last I admitted a man into Abernethy ward, with extensive varicose veins of the left leg and thigh. Seven eschars were made on the vessels below the knee, and in a month the wounds had healed. Previous to the operation, he had suffered severe pain in the limb, and often to so great a. degree as to compel his absence from work. I then proposed to him the radical cure of the disease abovethe knee, where the contortion of the vein was large, and its diameter was enormously increased, but he refused to undergo further detention in the hospital, saying that he had work before him of a more than usually profitable kind. At the expiration of two months he returned to the hospital. The cure of the veins treated by the Vienna paste was complete both as to sensation and to aspect, but he complained of severe suffering from the veins of the thigh. These were very prominent, and somewhat tender to the touch. I made eschars of about the fourth of an inch in diameter, on the four most prominent parts of the disease. On the following morning the whole surface was reddened and consolidated by lymph. The man suffered no further pain. The eschars came away on about the tenth day, and on the nineteenth the man left the hospital cured. I have at the present time under my care an officer of cavalry, who has suffered for the last year or two from considerable pain in the saphena vein of the right leg and thigh. The locality was such as to prevent the requisite pressure of the knee against the saddle, and he consequently rode with difficulty. I destroyed the vein along a track of about fifteen inches, by the formation of seven eschars, four of which are placed below, and three above the knee. A month has elapsed since the operation. The sloughs have all separated, and the ulcers have closed to about half their largest size. The diseased vein iSL entirely obliterated.
as the immediate consequence of the treatment. For a dozen years or more I have employed the Vienna paste as an escharotic, with a view to obliterate the saphena veins. I do not assert that this agent ought to supersede all other agents for this purpose; on the contrary, I think it exceedingly possible that some other may be yet discovered possessing greater merit; but all I desire to assert on behalf of the Vienna paste is, that for a number of years it has carried my intentions into effect, without danger or evil of any kind, and that I have never failed, in a list of some forty or fifty cases, to accomplish the object of its application-viz., the entire obliteration of the morbid structure beneath. The Vienna paste is a compound of quick-lime and potassa fusa, in the proportion of about three of the lime to two of the potash. The two powders should be finely powdered and kept separate in stoppered bottles; and when required for use, they should be combined in a paste by the addition of spirits of wine. A hole is cut in the centre of three or four thicknesses of fres7dy-made adhesive plaster, the aperture in which corresponds with the most prominent part of the veia. With regard to the number of these eschars, much will depend on the extent of the disease. If the vein be very tortuous and large, as many as eight or ten eschars may be required. I made on one occasion twelve in one leg and ten in the opposite leg of the same patient. With regard to size, I When I first ,think they can hardly be made too small. .adopted this treatment, I thought the larger the destruction of SECOND NOTE ON THE PHYSIOLOGICAL surface the more efficient the treatment; but it is not so. The TEST FOR STRYCHNIA. evil of large eschars is great, inasmuch as they produce ulcers of unnecessary magnitude, which are difficult to heal, and pro-I BY MARSHALL HALL, M.D., F.R.S., &c. tract recovery often very considerably; whereas the destruction of the skin and tissues beneath to an extent even within the ’breadth of the vein itself is sufficient to the entire and immeTo the Edito2- of THE LANCET. diate obliteration of the vessel. A circle of the fourth or third of an inch will, I believe, suffice for this purpose, even in the SIR,-I have been enabled to detect the 1/2500 part of a The plaster should be applied with .case of the largest vein. grain of the acetate of strychnia. some care, and made to adhere with exactness to the surface The young frog fresh from the pools is the most susceptible to. underneath. In determining the situation, I usually select the points in the track of the vein which are largest and most the influence of this extraordinary agent. prominent; and on these, the plaster, prepared as above deAll young animals are more susceptible than the adult of £ scribed, may be applied. It is desirable not to make the same species. paste too wet, or the plaster will not retain it within the rre- theThe frog is most susceptible of all. It is not less strychnoscribed circle, and the result will be an eschar at least half as large again as that proposed. As to the period of its applica- scopic than galvanoscopic. In proceeding with an inquiry we should begiz2 with the tion, the destruction of parts will be complete in from twenty minutes to half an hour, towards the expiration of which, and frog, because it is the most detective. We may proceed to use indeed often much earlier, all pain has ceased. The plasters other animals, but these can only detect a la2-ger dose of the may then be removed, and the paste carefully washed off with and The phenoare in nowise more satisfactory. poison, a soft It is not what kind of sponge. very important application mena in themthey in the than even are distinctive less is now made to the surface, but I usually order a well-made poulfrog. tice of linseed meal, to which a quantity of lard is added, and In one case I gave} of a grain of the acetate of strychnia. this is renewed night and morning until the eschars separate. to a cat. It proved fatal. Some time having elapsed, Mr. From the time of the destruction of the skin, the vein will Lloyd Bullock prepared the contents of the stomach, and we ’be obliterated, and in a day or two subsequently, its presence induced strychnism in three frogs in succession. The dose of will hardly be detected by the pressure of the finger. All that poison would scarcely have affected another cat or a rabbit. now remains is to force on the vital A kitten was killed by --?ö part of a grain, and an adult cat powers to the separation of the eschars and the healing of the circular ulcers, which will by fi of a grain of the acetate of strychnia. This would, I still expand by the elasticity of the skin around, as the sloughs should think, not have been detectible by another kitten or separate from the living texture. Having described the con- cat, as taken from the stomach. But many times less would dition of system inseparable from that in which the veins as- be deteetible and demonstrable by means of the strychnosume this varicose state, I need not tell you that you must scopic frog. draw largely on such agents, both medicinal and dietetic, as Prinoes-strMt, Hanover-.square. March. 1856.
335
portion
Clinical Lecture ON THE
TREATMENT OF VARICOSE VEINS. Delivered at St. Bartholomew’s
BY FREDERIC C. SURGEON TO
Hospital,
Feb. 1st, 1856.
SKEY, ESQ., F.R.S., THE HOSPITAL.
GENTLEMEN,ňAmongst the diseases of minor importance, frequent occurrence of which occasions a very large aggregate of discomfort, and, indeed, of suffering, may be classed
the
that of varicose veins. This abnormal condition of the venous tubes occupies the superficial veins of the lower extremity for the most part, but it may prevail extensively throughout the surface veins of the entire system. Some years ago I was consulted by a gentleman of about twenty-two years of age, each of whose extremities exhibited on its surface very remarkable congeries of veins, all in a varicose state, from the dorsal vessels of the hand to the summit of the cephalic, and throughout the entire length of the saphenae of the legs, both major and minor. As a general rule, however, the disease is confined to the saphena major of one or both lower extremities, being commonly limited to the vessel below the knee, though often extending above it. Under some circumstances, the ramifications, or rather the contorted trunk of the saphena, acquires a great magnitude, being in parts of its course equal to that of the index fiuger. When the disease occupies any
334
which
their devotion to their daily occupation. It is the occasional cause of a still greater evil: the smaller venous capillaries about the ancle, on which the brunt of the increased weight falls, become dilated, and the skin in that region is converted into a large discoloured patch of purple hue, into which one or
will
pints, and I need not tell you that this is an evil of no slight magnitude. Various have been the modes, and no less the degree of success, attending the treatment of this disagreeable Some twenty-five years ago, varicose veins were disease. largely experimented on in the various metropolitan hospitals of that day. The veins were divided, some directly, some subcutaneously; some were tied in one or more places, and some were laid open longitudinally with the lancet. The result of these experiments, performed, as I recollect, by surgeons of experience andjudgment, was, however, by no means satisfactory, and death resulted on more than one or two occasions
likely to be
promote healthy vital actions, such as bark, opium, iron, wine, brandy, and animal food. If your patient’s bowels become constipated, remove their contents by a mild laxative; but as a general, almost a universal rule, leave the ’’I secretions" to take care of themselves. Indeed, I will venture to more of the larger vessels may be traced, often grooving the say that I deem it of so much importance to retain in the alisurface of the bone. This discoloured patch has a tendency to mentary canal all the nourishment that is attainable from the advance into the state of chronic inflammation, in which the food, that I would suggest, should you adopt the opinion that larger vessel ulcerates, and a large quantity of blood may man cannot enjoy health without the frequent employment of escape from the vessel before any rational attempt is resorted purgative medicine, that you had better leave varicose veins and to to arrest it. I calculated the quantity of blood lost by a their treatment to your neighbour. As a general rule, you may patient under these circumstances at between two and three rely upon it that the actions of a man’s bowels are far more diurnal and
regular on a full
diet than
on a
limited
one.
In the month of July last I admitted a man into Abernethy ward, with extensive varicose veins of the left leg and thigh. Seven eschars were made on the vessels below the knee, and in a month the wounds had healed. Previous to the operation, he had suffered severe pain in the limb, and often to so great a. degree as to compel his absence from work. I then proposed to him the radical cure of the disease abovethe knee, where the contortion of the vein was large, and its diameter was enormously increased, but he refused to undergo further detention in the hospital, saying that he had work before him of a more than usually profitable kind. At the expiration of two months he returned to the hospital. The cure of the veins treated by the Vienna paste was complete both as to sensation and to aspect, but he complained of severe suffering from the veins of the thigh. These were very prominent, and somewhat tender to the touch. I made eschars of about the fourth of an inch in diameter, on the four most prominent parts of the disease. On the following morning the whole surface was reddened and consolidated by lymph. The man suffered no further pain. The eschars came away on about the tenth day, and on the nineteenth the man left the hospital cured. I have at the present time under my care an officer of cavalry, who has suffered for the last year or two from considerable pain in the saphena vein of the right leg and thigh. The locality was such as to prevent the requisite pressure of the knee against the saddle, and he consequently rode with difficulty. I destroyed the vein along a track of about fifteen inches, by the formation of seven eschars, four of which are placed below, and three above the knee. A month has elapsed since the operation. The sloughs have all separated, and the ulcers have closed to about half their largest size. The diseased vein iSL entirely obliterated.
as the immediate consequence of the treatment. For a dozen years or more I have employed the Vienna paste as an escharotic, with a view to obliterate the saphena veins. I do not assert that this agent ought to supersede all other agents for this purpose; on the contrary, I think it exceedingly possible that some other may be yet discovered possessing greater merit; but all I desire to assert on behalf of the Vienna paste is, that for a number of years it has carried my intentions into effect, without danger or evil of any kind, and that I have never failed, in a list of some forty or fifty cases, to accomplish the object of its application-viz., the entire obliteration of the morbid structure beneath. The Vienna paste is a compound of quick-lime and potassa fusa, in the proportion of about three of the lime to two of the potash. The two powders should be finely powdered and kept separate in stoppered bottles; and when required for use, they should be combined in a paste by the addition of spirits of wine. A hole is cut in the centre of three or four thicknesses of fres7dy-made adhesive plaster, the aperture in which corresponds with the most prominent part of the veia. With regard to the number of these eschars, much will depend on the extent of the disease. If the vein be very tortuous and large, as many as eight or ten eschars may be required. I made on one occasion twelve in one leg and ten in the opposite leg of the same patient. With regard to size, I When I first ,think they can hardly be made too small. .adopted this treatment, I thought the larger the destruction of SECOND NOTE ON THE PHYSIOLOGICAL surface the more efficient the treatment; but it is not so. The TEST FOR STRYCHNIA. evil of large eschars is great, inasmuch as they produce ulcers of unnecessary magnitude, which are difficult to heal, and pro-I BY MARSHALL HALL, M.D., F.R.S., &c. tract recovery often very considerably; whereas the destruction of the skin and tissues beneath to an extent even within the ’breadth of the vein itself is sufficient to the entire and immeTo the Edito2- of THE LANCET. diate obliteration of the vessel. A circle of the fourth or third of an inch will, I believe, suffice for this purpose, even in the SIR,-I have been enabled to detect the 1/2500 part of a The plaster should be applied with .case of the largest vein. grain of the acetate of strychnia. some care, and made to adhere with exactness to the surface The young frog fresh from the pools is the most susceptible to. underneath. In determining the situation, I usually select the points in the track of the vein which are largest and most the influence of this extraordinary agent. prominent; and on these, the plaster, prepared as above deAll young animals are more susceptible than the adult of £ scribed, may be applied. It is desirable not to make the same species. paste too wet, or the plaster will not retain it within the rre- theThe frog is most susceptible of all. It is not less strychnoscribed circle, and the result will be an eschar at least half as large again as that proposed. As to the period of its applica- scopic than galvanoscopic. In proceeding with an inquiry we should begiz2 with the tion, the destruction of parts will be complete in from twenty minutes to half an hour, towards the expiration of which, and frog, because it is the most detective. We may proceed to use indeed often much earlier, all pain has ceased. The plasters other animals, but these can only detect a la2-ger dose of the may then be removed, and the paste carefully washed off with and The phenoare in nowise more satisfactory. poison, a soft It is not what kind of sponge. very important application mena in themthey in the than even are distinctive less is now made to the surface, but I usually order a well-made poulfrog. tice of linseed meal, to which a quantity of lard is added, and In one case I gave} of a grain of the acetate of strychnia. this is renewed night and morning until the eschars separate. to a cat. It proved fatal. Some time having elapsed, Mr. From the time of the destruction of the skin, the vein will Lloyd Bullock prepared the contents of the stomach, and we ’be obliterated, and in a day or two subsequently, its presence induced strychnism in three frogs in succession. The dose of will hardly be detected by the pressure of the finger. All that poison would scarcely have affected another cat or a rabbit. now remains is to force on the vital A kitten was killed by --?ö part of a grain, and an adult cat powers to the separation of the eschars and the healing of the circular ulcers, which will by fi of a grain of the acetate of strychnia. This would, I still expand by the elasticity of the skin around, as the sloughs should think, not have been detectible by another kitten or separate from the living texture. Having described the con- cat, as taken from the stomach. But many times less would dition of system inseparable from that in which the veins as- be deteetible and demonstrable by means of the strychnosume this varicose state, I need not tell you that you must scopic frog. draw largely on such agents, both medicinal and dietetic, as Prinoes-strMt, Hanover-.square. March. 1856.
335