- Email: [email protected]
Leg ulcers of venous origin: From ancient to modern times
HISTORICAL VIGNETTES IN VENOUS SURGERY Norman M. Rich, MD, Section Editor From the Society for Vascular Surgery
Leg ulcers of venous origin: From ancient to modern times J. Leonel Villavicencio, MD, Bethesda, Md “On the Subject of Leg Ulcers” “When we consider how filthy the habits of many persons are, who often leave their feet unwashed for weeks and months together, it cannot be wandered that skin so neglected should in the decline of life, possess a very imperfect vitality. Daily washing the lower limbs with a piece of flannel and yellow soap and water, is one of the best means of reviving their decayed powers . . . . . . . and finally, the limb should be well and evenly bandaged from the toes to the knee, observing that the bandage is to be applied most tightly below, and more loosely by degrees as it ascends . . .”1
Venous leg ulcers have plagued humanity ever since Homo sapiens learned that the erect position allowed him to have a wider view of his hunting horizon. In doing this, the human race began a struggle against the deleterious effects of the hydrostatic effects of gravity. In the erect posture, there is a tendency for blood to collect in the more dependent areas such as the lower extremities. In healthy individuals, up to 500 mL of blood may accumulate in the legs after standing 1 hour, and the volume of the lower leg may increase by 3% to 5%. This can be reversed quickly by walking or lying down. Compensatory mechanisms, such as the venous tone, contraction of the calf muscles, and the venous valves, play a pivotal role in the venous return to the heart.
From the Department of Surgery, School of Medicine, Uniformed Services University of the Health Sciences. Author conflict of interest: none. Presented at the 2012 Vascular Annual Meeting of the Society for Vascular Surgery, National Harbor, Md, June 7-9, 2012. Reprint requests: J. Leonel Villavicencio, MD, Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814 (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 2213-333X/$36.00 Published by Elsevier Inc. on behalf of the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvsv.2012.08.003
96
Individuals suffering from venous disorders constitute the large majority of patients attending the vascular clinics in Latin America, the United States, Canada, and Europe. Bosanquet2 writes about venous disease being a “new international challenge,” calculating that the cost of treatment of venous diseases, including physician charges, prescription medicines, disability, and loss of work ranges from 1.5% in Germany to 5% of the total budget for health care in France. The prevalence of venous leg ulcers in Europe has been documented to range from 1% to 1.5%.3 In the United States, chronic venous insufficiency with venous ulcers affects 4% of people aged >65 years.4 In his prophetic Presidential Address, “A Venous Renaissance,” the late Michael Hume, President of the American Venous Forum, wrote: “Two examples of venous disease, both quite widespread, offer distinctly different challenges: varicose veins and leg ulcers. The cost of care in this country is ballooning; the ‘system’ of care for leg ulcers is an extravagant example. Yes. a Venous Renaissance is needed. It will fall to vascular surgeons however, to lead the post-graduate education of the health care team. . . if any impact is to be made on the problem at national level.”4 With the current knowledge in mind about venous disease and leg ulcers, it is always healthy in medicine to look back to history and examine the thoughts, theories, and myths that have existed among our predecessors on the etiology and management of a disease so prevalent as venous disease and leg ulcers in particular. EARLY HISTORY In the Ebers Papyrus (ca 1559 B.C.), there is mention of varicose veins, and surgery is not recommended.5 Hippocrates (460-377 B.C.) described leg ulcers associated with varicose veins and gave this advice, “in the case of an ulcer it is not expedient to stand, more specially if the ulcer is situated in the leg. The sore is frequently wiped with a sponge and a dry piece of clean cloth is applied. Ulcers which are foul will not heal until they are cleansed. When the parts adjoining to a sore are inflamed or gangrenous, or when there is a varix in the part, the ulcer will not heal.”6
JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC DISORDERS Volume 1, Number 1
For nearly 15 centuries, the theory of humors, supported by Galen and taken from Hippocrates, predominated among the medical thinking, and varices were thought to originate by the weight of stagnant blood on the veins. As a result of the humoral theory, it was considered dangerous in those years to heal a leg ulcer, even though Celsus, Galen, and Hippocrates did not share these fears. Aurelius Cornelius Celsus7 (25 B.C.-50 A.D.) wrote that “varicose veins were to be treated by avulsion with a blunt hook.” This, together with Claudius Galen’s8 approach to the management of varices, are probably some of the earliest writings on the currently used minimally invasive “vein hook technique” for the avulsion of varicose veins.9 Ambroise Pare (1510-1590) and even earlier, Paulus Aeginata (c.625-690?),10 a 7th century Byzantine Greek physician known for writing the Medical Encyclopedia Medical Compendium in Seven Books that contained the Western medical knowledge and was unrivaled in accuracy and completeness, had described the operation. Aeginata in his Sixth Book on Surgery gave a careful description on how to do it: Wherefore having washed the man and applied a ligature round the upper part of the thigh, we are to direct him to walk about and when the vein becomes distended we are to mark its situation with writing ink or colirium in the extent of three fingers breath or little more and having placed the man in a reclining posture we apply another ligature above the knee; where the vein is distended we make an incision upon the mark with a scalpel but not to a greater depth than the thickness of the skin, lest we divide
Villavicencio 97
the vein, and having separated the lips of the wound with hooks and having raised the vessel with a blind hook. and introduced under it a needle having a double thread we cut the double of it and then. we may either cut out the portion intermediate between the ligatures or suffer it to remain until it drops out of its own accord with the ligatures; . . . then we put a dry pledget into the wound and apply over it an oblong compress soaked in wine and oil and secure it with a bandage.
Avicenna11 (980-1037) had the certainty that, “leg ulcer in old people should be left alone and if healed should be opened to drain for humors that if not drained may produce serious illness.” Thomas Vicary (1536) wrote that “the Legges when wounded are very perilous because unto them runneth a great quantity of humors.”12 MIDDLE AGES During this period in history, there were outstanding physicians that made important contributions to the understanding and management of venous leg ulcers. Given our present knowledge on the anatomy and pathophysiology of venous disorders, it is remarkable to observe in this historical review the insight, knowledge, and the sharp clinical senses demonstrated by our colleagues of those years. They used their sharp senses of observation, careful palpation, percussion, and auscultation with their own ear applied directly over the chest to diagnose pneumonia and other respiratory or cardiac ailments, their senses of smell and sight could detect with accuracy infections with Pseudomonas aeruginosa that has a greenish, bluish color and very pungent particular odor, as well as other infected wounds. With
Fig 1. A, Richard Wiseman (1622-1676) was a strong proponent of compression as a cornerstone in the management of the venous leg ulcer. B, Wiseman designed an effective compression laced boot made of soft dog skin. (Reprinted with permission.)
98 Villavicencio
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very limited resources, they often arrived at diagnostic conclusions not too distant from reality even though they lacked the technologic and diagnostic armamentarium that we currently have. As shown by Paulus Aeginata in a description of a surgical technique for varicose veins in the 7th century, he used preoperative vein marking in the erect position, used vein hooks, double ligatures, and the tourniquet in a similar manner as we do in this day and age! It would be difficult if not impossible within the limited scope of this historical review on venous leg ulcers to give a detailed account of all and every important past contribution made in this field. However, a few individuals stand out in this field. Richard Wiseman13 (Fig 1, A) wrote: The Cure of these Ulcers wuth Varix are real or palliative. The Real or Perfect Cure proposed by the Ancients I have delivered to you in the Chapter of a Simple Varix: it is by making an Incision in the Skin and taking up the Vein, and tying it, But this way hath not been admitted (to my knowledge) among us; nor have I often seen that a Varicouse Ulcer could be cured by cutting off the Varix leading to the Ulcer, there been commonly more Veins concerned in it. The Palliative Cure consists in dressing the Ulcer with Degestives, according as the Ulcer is Sanious or Sordid, and the while by good Bandage or a laced Stocking to repress the Humors impacted in the Part; by which Bandage the Lips of the Ulcer are disposed to cicatriz with the Ulcer. I called this method Palliative, for that it commonly lasts no longer then the laced Stocking is worn. In the Cure of these Ulcers, if there is Plethora, it may be necessary that the Body be Purged, and a Vein opened.
Wiseman devised a laced stocking (Fig 1, B) made of soft leather, such as from deer or dog skin. This method provided the option of graduating the degree of compression in a manner very similar to the currently used CircAid that instead of leather laces uses Velcro bands to adjust the degree of compression. Thomas Baynton (1797)1 described a new method “to treat Old Ulcers of the Leg.” Nixon14 wrote a biographical sketch about Baynton: A Descriptive Account of a New Method of treating old Ulcers of the Legs was published in 1707 and dedicated to Dr. A. Fothergill, F.R.R. laid the foundation stone of the great name which he acquired, his plan being adopted extensively both by the Army and Navy. The method consisted in the neat and regular application of adhesive strips to the limb and subsequently keeping the whole moistened with cold water. The principle which is nothing more than affording a support to the parts, is as old as Wiseman. Mr Baynton’s master, Percival Pott, of London also strenuously recommended the laced stocking or the tight bandage, which are the same thing in effect, but the adhesive has the advantage of being cheaper and always at hand.” To this day (1830), I am not aware that any improvement has been made upon his suggestion, and the method having stood the test of 33 years’ experience, is a sufficient proof of its merits. The great success of his book on Ulcers had given to
Fig 2. John Gay (1812-1885). Gay made profound observations and anatomic investigations on the venous and arterial systems that made an impact on the thoughts of future investigators. (Reprinted with permission.) Mr. Baynton’s mind a high opinion of the superiority of his own attainments, and he thought it little else than impertinence for anyone to dissent from his ipse dixit.
Baynton’s biographical sketch contains an account of rivalries, criticisms, and envy from colleagues from the Bristol Royal Infirmary, not unlike those observed nowadays! John Gay (1812-1885; Fig 2) made a profound observation on venous ulceration when he wrote that, “Ulceration is not a direct consequence of varicosity but of other conditions of the venous system with which varicosity is not infrequently a complication but without which neither one of the allied skin affections (induration and bronzing) is met with conditions which involve obstruction of the trunk veins deep and superficial, either from impediment on the venous side, or incompetency on the arterial or from both causes combined.”15 The critical role of compression that in modern times is considered a cornerstone in the management of venous disease was keenly appreciated by some of the workers mentioned above and others that followed, among them, John Bell, whose work is worth mentioning. He wrote, “Of these ulcers, that which is in a manner peculiar to the lower extremities is by far the most frequent. The cause of this weakness in the lower extremities is their dependent posture and therefore these ulcers are cured by keeping the limb on a horizontal position on a level with the body.
JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC DISORDERS Volume 1, Number 1
Uniformed pressure by means of strips or sticking plaster and bandage must at the same time be applied. In warm weather, cold water pumped upon the limb, will be of great advantage in expediting the cure.”16 During the 16th, 17th, and 18th centuries, there were many other prominent individuals who, in one form or another, contributed to our understanding of venous disease. Given the limitations of this review, we will only mention their names and a brief outline of their contributions: Everard Home17 (1801) wrote the book Practical Observations on the Treatment of Ulcers of the Legs Considered as a Branch of Military Surgery. Fabricius ab Aquapendente’s (1533-1619) work led to the discovery of venous valves, a monumental contribution that established the bases for the discovery of the blood circulation by William Harvey (1578-1657), who had worked with Fabricius in Padua. Paul Gerson Unna (1850-1929), a German dermatologist from Hamburg convinced of the usefulness of compression, developed the Unna boot for the treatment of leg ulcers and other skin ailments (a mixture of gelatin, zinc oxide, glycerin, and water), B. Brodie and F. Trendelenburg described a diagnostic tourniquet test and an operation for the incompetent saphenous vein. These were the beginnings of the “modern age” of surgery of the saphenous system that continued with Charles Mayo, who in 1888 performed the first operation on a patient with varicose veins at St. Mary’s Hospital in Rochester, Minnesota. CURRENT CONCEPTS ON THE VENOUS ULCER During the last 50 years, clinicians and investigators interested in venous disorders have been occupied mainly in clarifying as much as possible the mechanisms involved in the pathophysiology of the venous leg ulcer. Sir Norman Browse,18 in Chapter 13 of his excellent book Diseases of the Veins: Pathology, Diagnosis and Treatment, analyzes and discusses what he considers important publications on the subject of etiology of the venous leg ulcer and presents his own views. He stresses the importance of (1) the “calf pump mechanism,” (2) deep vein post-thrombotic damage, and (3) calf perforator’s incompetence, in the etiology of microcirculation changes and tissue anoxia. Browse and his group have investigated the development of pericellular fibrin cuffs that block oxygen uptake at cellular level.
Villavicencio 99
The dormant interest in venous disorders in the United States had an important increase after the foundation of the American Venous Forum, an organization that has greatly contributed to stimulate the search into the microcirculation and changes at molecular level, attracting many serious investigators to the field.
REFERENCES 1. Thomas Baynton (1761-1830). Descriptive account of a new method of treating old ulcers of the leg. Bristol, England: Smith, Elder & co; 1885 [Reference in: Nixon JA. Thomas Baynton, 1761-1820. Proc R Soc Med 1915;8(Sect Hist Med):95-102]. 2. Bosanquet N. A new international challenge. Phlebology 1996;11:6-9. 3. Dale JJ, Callam MJ, Ruckley CV. Chronic ulcers of the leg: a study of prevalence in a Scottish community. Health Bull 1983;41:310-4. 4. Hume M. A venous renaissance. J Vasc Surg 1992;15:947-51. 5. Major RH. A history of medicine, Vol 1. Blackwell: Oxford; 1954. 6. Hippocrates. The genuine works of Hippocrates. Section on ulcers. Vol. 1. Translated from the Greek with a preliminary discourse and annotations by Francis Adams L.L.D. London: Close; 1893. p. 790-1. 7. Celsus AC. Of medicine in eight books. Translation by James Grieve. Churchill: London; 1756. 8. Galen C. Ad scripti libri. Vincentium Valgrisium: Venice; 1562; p 34. 9. Waddell BE, Harkins B, LePage PA, Modesto VL, Villavicencio JL. The crochet hook method of stab avulsion phlebectomy for varicose veins. Am J Surg 1996;172:278-80. 10. Paulus AeginataePaul of Aegina (c.625) Book 6 on surgery. The medical works of Paulus Aeginata. First English translation by Francis Adams 1844-47. The seven books of Paulus Aeginata. London: Sydenham Society; 1896. 11. Avicenna. De ulceribus. Lib. IV. Quoted by M. Underwood 1783 in: A treatise upon ulcers of the legs. London: Mathews; 1783. 12. Vicary T. The Englishman’s treasure. Alsop and Fawcet: London; 1636. 13. Wiseman, Richard. 1622-1676. Severall chirurgicall treatises. Book II, chapter XI. Of ulcers with varices. London: Flesher and Macock; 1676. p. 200-1. 14. Nixon JA. Thomas Baynton, 1761-1820. Proc R Soc Med 1618 (Section of the History of Medicine) 1915. J Royal Soc Med. Formerly published as Medico-Chirurgical Transactions 1809-1907:95-102. 15. Gay J. On varicose diseases of the lower extremities. The Lettsomian Lectures of 1867. London: Churchill; 1868. 16. Bell J. Surgeon. On the principles of surgery. Section II on Ulcers. New York: Collins and Perkins; 1810. p. 33. 17. Home E. Practical observations on the treatment of ulcers of the legs, considered as a branch of military surgery. British Library: London; 1797; (4) VIII. 295(1). p. 8. 18. Browse N, Burnand K, Thomas ML. Venous ulceration: pathology. In: Diseases of the Veins. Edward Arnold: London, Baltimore, Melbourne; 1988. p. 349-69.
Submitted Aug 22, 2012; accepted Aug 29, 2012.
Leg ulcers of venous origin: From ancient to modern times J. Leonel Villavicencio, MD, Bethesda, Md “On the Subject of Leg Ulcers” “When we consider how filthy the habits of many persons are, who often leave their feet unwashed for weeks and months together, it cannot be wandered that skin so neglected should in the decline of life, possess a very imperfect vitality. Daily washing the lower limbs with a piece of flannel and yellow soap and water, is one of the best means of reviving their decayed powers . . . . . . . and finally, the limb should be well and evenly bandaged from the toes to the knee, observing that the bandage is to be applied most tightly below, and more loosely by degrees as it ascends . . .”1
Venous leg ulcers have plagued humanity ever since Homo sapiens learned that the erect position allowed him to have a wider view of his hunting horizon. In doing this, the human race began a struggle against the deleterious effects of the hydrostatic effects of gravity. In the erect posture, there is a tendency for blood to collect in the more dependent areas such as the lower extremities. In healthy individuals, up to 500 mL of blood may accumulate in the legs after standing 1 hour, and the volume of the lower leg may increase by 3% to 5%. This can be reversed quickly by walking or lying down. Compensatory mechanisms, such as the venous tone, contraction of the calf muscles, and the venous valves, play a pivotal role in the venous return to the heart.
From the Department of Surgery, School of Medicine, Uniformed Services University of the Health Sciences. Author conflict of interest: none. Presented at the 2012 Vascular Annual Meeting of the Society for Vascular Surgery, National Harbor, Md, June 7-9, 2012. Reprint requests: J. Leonel Villavicencio, MD, Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814 (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 2213-333X/$36.00 Published by Elsevier Inc. on behalf of the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvsv.2012.08.003
96
Individuals suffering from venous disorders constitute the large majority of patients attending the vascular clinics in Latin America, the United States, Canada, and Europe. Bosanquet2 writes about venous disease being a “new international challenge,” calculating that the cost of treatment of venous diseases, including physician charges, prescription medicines, disability, and loss of work ranges from 1.5% in Germany to 5% of the total budget for health care in France. The prevalence of venous leg ulcers in Europe has been documented to range from 1% to 1.5%.3 In the United States, chronic venous insufficiency with venous ulcers affects 4% of people aged >65 years.4 In his prophetic Presidential Address, “A Venous Renaissance,” the late Michael Hume, President of the American Venous Forum, wrote: “Two examples of venous disease, both quite widespread, offer distinctly different challenges: varicose veins and leg ulcers. The cost of care in this country is ballooning; the ‘system’ of care for leg ulcers is an extravagant example. Yes. a Venous Renaissance is needed. It will fall to vascular surgeons however, to lead the post-graduate education of the health care team. . . if any impact is to be made on the problem at national level.”4 With the current knowledge in mind about venous disease and leg ulcers, it is always healthy in medicine to look back to history and examine the thoughts, theories, and myths that have existed among our predecessors on the etiology and management of a disease so prevalent as venous disease and leg ulcers in particular. EARLY HISTORY In the Ebers Papyrus (ca 1559 B.C.), there is mention of varicose veins, and surgery is not recommended.5 Hippocrates (460-377 B.C.) described leg ulcers associated with varicose veins and gave this advice, “in the case of an ulcer it is not expedient to stand, more specially if the ulcer is situated in the leg. The sore is frequently wiped with a sponge and a dry piece of clean cloth is applied. Ulcers which are foul will not heal until they are cleansed. When the parts adjoining to a sore are inflamed or gangrenous, or when there is a varix in the part, the ulcer will not heal.”6
JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC DISORDERS Volume 1, Number 1
For nearly 15 centuries, the theory of humors, supported by Galen and taken from Hippocrates, predominated among the medical thinking, and varices were thought to originate by the weight of stagnant blood on the veins. As a result of the humoral theory, it was considered dangerous in those years to heal a leg ulcer, even though Celsus, Galen, and Hippocrates did not share these fears. Aurelius Cornelius Celsus7 (25 B.C.-50 A.D.) wrote that “varicose veins were to be treated by avulsion with a blunt hook.” This, together with Claudius Galen’s8 approach to the management of varices, are probably some of the earliest writings on the currently used minimally invasive “vein hook technique” for the avulsion of varicose veins.9 Ambroise Pare (1510-1590) and even earlier, Paulus Aeginata (c.625-690?),10 a 7th century Byzantine Greek physician known for writing the Medical Encyclopedia Medical Compendium in Seven Books that contained the Western medical knowledge and was unrivaled in accuracy and completeness, had described the operation. Aeginata in his Sixth Book on Surgery gave a careful description on how to do it: Wherefore having washed the man and applied a ligature round the upper part of the thigh, we are to direct him to walk about and when the vein becomes distended we are to mark its situation with writing ink or colirium in the extent of three fingers breath or little more and having placed the man in a reclining posture we apply another ligature above the knee; where the vein is distended we make an incision upon the mark with a scalpel but not to a greater depth than the thickness of the skin, lest we divide
Villavicencio 97
the vein, and having separated the lips of the wound with hooks and having raised the vessel with a blind hook. and introduced under it a needle having a double thread we cut the double of it and then. we may either cut out the portion intermediate between the ligatures or suffer it to remain until it drops out of its own accord with the ligatures; . . . then we put a dry pledget into the wound and apply over it an oblong compress soaked in wine and oil and secure it with a bandage.
Avicenna11 (980-1037) had the certainty that, “leg ulcer in old people should be left alone and if healed should be opened to drain for humors that if not drained may produce serious illness.” Thomas Vicary (1536) wrote that “the Legges when wounded are very perilous because unto them runneth a great quantity of humors.”12 MIDDLE AGES During this period in history, there were outstanding physicians that made important contributions to the understanding and management of venous leg ulcers. Given our present knowledge on the anatomy and pathophysiology of venous disorders, it is remarkable to observe in this historical review the insight, knowledge, and the sharp clinical senses demonstrated by our colleagues of those years. They used their sharp senses of observation, careful palpation, percussion, and auscultation with their own ear applied directly over the chest to diagnose pneumonia and other respiratory or cardiac ailments, their senses of smell and sight could detect with accuracy infections with Pseudomonas aeruginosa that has a greenish, bluish color and very pungent particular odor, as well as other infected wounds. With
Fig 1. A, Richard Wiseman (1622-1676) was a strong proponent of compression as a cornerstone in the management of the venous leg ulcer. B, Wiseman designed an effective compression laced boot made of soft dog skin. (Reprinted with permission.)
98 Villavicencio
JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC DISORDERS January 2013
very limited resources, they often arrived at diagnostic conclusions not too distant from reality even though they lacked the technologic and diagnostic armamentarium that we currently have. As shown by Paulus Aeginata in a description of a surgical technique for varicose veins in the 7th century, he used preoperative vein marking in the erect position, used vein hooks, double ligatures, and the tourniquet in a similar manner as we do in this day and age! It would be difficult if not impossible within the limited scope of this historical review on venous leg ulcers to give a detailed account of all and every important past contribution made in this field. However, a few individuals stand out in this field. Richard Wiseman13 (Fig 1, A) wrote: The Cure of these Ulcers wuth Varix are real or palliative. The Real or Perfect Cure proposed by the Ancients I have delivered to you in the Chapter of a Simple Varix: it is by making an Incision in the Skin and taking up the Vein, and tying it, But this way hath not been admitted (to my knowledge) among us; nor have I often seen that a Varicouse Ulcer could be cured by cutting off the Varix leading to the Ulcer, there been commonly more Veins concerned in it. The Palliative Cure consists in dressing the Ulcer with Degestives, according as the Ulcer is Sanious or Sordid, and the while by good Bandage or a laced Stocking to repress the Humors impacted in the Part; by which Bandage the Lips of the Ulcer are disposed to cicatriz with the Ulcer. I called this method Palliative, for that it commonly lasts no longer then the laced Stocking is worn. In the Cure of these Ulcers, if there is Plethora, it may be necessary that the Body be Purged, and a Vein opened.
Wiseman devised a laced stocking (Fig 1, B) made of soft leather, such as from deer or dog skin. This method provided the option of graduating the degree of compression in a manner very similar to the currently used CircAid that instead of leather laces uses Velcro bands to adjust the degree of compression. Thomas Baynton (1797)1 described a new method “to treat Old Ulcers of the Leg.” Nixon14 wrote a biographical sketch about Baynton: A Descriptive Account of a New Method of treating old Ulcers of the Legs was published in 1707 and dedicated to Dr. A. Fothergill, F.R.R. laid the foundation stone of the great name which he acquired, his plan being adopted extensively both by the Army and Navy. The method consisted in the neat and regular application of adhesive strips to the limb and subsequently keeping the whole moistened with cold water. The principle which is nothing more than affording a support to the parts, is as old as Wiseman. Mr Baynton’s master, Percival Pott, of London also strenuously recommended the laced stocking or the tight bandage, which are the same thing in effect, but the adhesive has the advantage of being cheaper and always at hand.” To this day (1830), I am not aware that any improvement has been made upon his suggestion, and the method having stood the test of 33 years’ experience, is a sufficient proof of its merits. The great success of his book on Ulcers had given to
Fig 2. John Gay (1812-1885). Gay made profound observations and anatomic investigations on the venous and arterial systems that made an impact on the thoughts of future investigators. (Reprinted with permission.) Mr. Baynton’s mind a high opinion of the superiority of his own attainments, and he thought it little else than impertinence for anyone to dissent from his ipse dixit.
Baynton’s biographical sketch contains an account of rivalries, criticisms, and envy from colleagues from the Bristol Royal Infirmary, not unlike those observed nowadays! John Gay (1812-1885; Fig 2) made a profound observation on venous ulceration when he wrote that, “Ulceration is not a direct consequence of varicosity but of other conditions of the venous system with which varicosity is not infrequently a complication but without which neither one of the allied skin affections (induration and bronzing) is met with conditions which involve obstruction of the trunk veins deep and superficial, either from impediment on the venous side, or incompetency on the arterial or from both causes combined.”15 The critical role of compression that in modern times is considered a cornerstone in the management of venous disease was keenly appreciated by some of the workers mentioned above and others that followed, among them, John Bell, whose work is worth mentioning. He wrote, “Of these ulcers, that which is in a manner peculiar to the lower extremities is by far the most frequent. The cause of this weakness in the lower extremities is their dependent posture and therefore these ulcers are cured by keeping the limb on a horizontal position on a level with the body.
JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC DISORDERS Volume 1, Number 1
Uniformed pressure by means of strips or sticking plaster and bandage must at the same time be applied. In warm weather, cold water pumped upon the limb, will be of great advantage in expediting the cure.”16 During the 16th, 17th, and 18th centuries, there were many other prominent individuals who, in one form or another, contributed to our understanding of venous disease. Given the limitations of this review, we will only mention their names and a brief outline of their contributions: Everard Home17 (1801) wrote the book Practical Observations on the Treatment of Ulcers of the Legs Considered as a Branch of Military Surgery. Fabricius ab Aquapendente’s (1533-1619) work led to the discovery of venous valves, a monumental contribution that established the bases for the discovery of the blood circulation by William Harvey (1578-1657), who had worked with Fabricius in Padua. Paul Gerson Unna (1850-1929), a German dermatologist from Hamburg convinced of the usefulness of compression, developed the Unna boot for the treatment of leg ulcers and other skin ailments (a mixture of gelatin, zinc oxide, glycerin, and water), B. Brodie and F. Trendelenburg described a diagnostic tourniquet test and an operation for the incompetent saphenous vein. These were the beginnings of the “modern age” of surgery of the saphenous system that continued with Charles Mayo, who in 1888 performed the first operation on a patient with varicose veins at St. Mary’s Hospital in Rochester, Minnesota. CURRENT CONCEPTS ON THE VENOUS ULCER During the last 50 years, clinicians and investigators interested in venous disorders have been occupied mainly in clarifying as much as possible the mechanisms involved in the pathophysiology of the venous leg ulcer. Sir Norman Browse,18 in Chapter 13 of his excellent book Diseases of the Veins: Pathology, Diagnosis and Treatment, analyzes and discusses what he considers important publications on the subject of etiology of the venous leg ulcer and presents his own views. He stresses the importance of (1) the “calf pump mechanism,” (2) deep vein post-thrombotic damage, and (3) calf perforator’s incompetence, in the etiology of microcirculation changes and tissue anoxia. Browse and his group have investigated the development of pericellular fibrin cuffs that block oxygen uptake at cellular level.
Villavicencio 99
The dormant interest in venous disorders in the United States had an important increase after the foundation of the American Venous Forum, an organization that has greatly contributed to stimulate the search into the microcirculation and changes at molecular level, attracting many serious investigators to the field.
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Submitted Aug 22, 2012; accepted Aug 29, 2012.