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HISTORY OF THE TREATMENT OF CHRONIC VENOUS INSUFFICIENCY
The changes occurring in the lower limb due to disturbance of the normal blood flow in the veins have been the subject of many medical manuscripts. This chapter is a synopsis of the history of some methods of treatment of this condition, and indicates how little we have changed some of our basic principles.
On the subject of treatment for varicose veins, Hippocrates, in 500 B.C. (Adams, 1886), wrote: 'When a varix is on the fore part of the leg and is very superficial or below the flesh, and the leg is black and seems to stand in need of having blood evacuated from it, such swellings are not by any means to be cut open, for generally large ulcers are the consequence of the incision, owing to the influx from the varix. But the varix itself is to be punctured in many places as circumstances may indicate.' Any success achieved by this method of treatment was probably due to thrombosis of the vein wall following trauma and infection. In addition, it is likely that compression was applied to prevent bleeding. Galen (A.D. 130-210) (Adams, 1844), advocated a more radical approach similar to present-day practice: he tore out tortuous veins with a hook.
Galen (A.D. 130-210) in the time of Tiberius Caesar, was a prolific medical author, but was classified by Pliny as a man of letters rather than a doctor and therefore was largely ignored by Roman physicians of his time. In his view the treatment for varicose veins was excision or cauterizing.
The teachings of Hippocrates and Galen were considered as medical dogma from the time of the Roman Empire until the Renaissance, and modifications of their treatments are still advocated.
The Greek, Paulus Aegineta (A.D. 625-690) (Adams, 1844), favoured ligation of the long saphenous vein long before Trendelenberg. He wrote: 'Varices of the leg may be operated upon in a manner similar to that for varicocele, making the attempt upon those in the inner parts of the thigh where they gradually arise, for below this they are divided into many ramifications. A tourniquet is placed upon the thigh, and the patient walks. When the vein becomes distended a mark is made with writing ink or collyrium. Having placed the man in a reclining position with his leg extended we apply another tourniquet above the knee, and where the vein is distended we make an incision through the skin. The vein is freed and tourniquets are removed. A double thread is introduced under the vein and so cut as to make two ligatures, and the vein is opened in the middle, and as much blood as is required is evacuated. The wound is dressed with a pledget in it and with an oblong compress soaked in wine and oil. It is then bandaged.'
Albucasis (A.D. 1013-1106) (Garrison, 1929) borrowed heavily from the writings of Aegineta and favoured a form of ligation and stripping, or dissection of the superficial varicosities. Therefore it can be said that by the eleventh century the major surgical principles of treatment of varicose veins were well outlined. Only the subfascial ligation of perforating veins and injection therapy remained to be described.
The famous barber-surgeon, Ambroise Paré (A.D. 1510-1590) (Paget., 1910) modified the techniques of Aegineta and Albucasis, favouring ligation at the site of the varix, and sometimes, as Celsus advised, cautery, causing an ulcer which ultimately healed by a hard cicatrix. A century later the leading German surgeon, Heister (1768), recommended bleeding, a diet which amounted to near starvation, and the application of bandages to the legs, so that the coats of the vein might be strengthened.
Christopher Ubren (Franklin, 1937) and his associates, in 1656, are reputed to have been the first to introduce drugs intravenously. Using a metal tube they introduced opium into the veins of a dog. Similar injections were given to a human a few years later by J. D. Major and Casper Scotus (Franklin, 1937).
However, it was Francis Rynd in 1845, and Parvez in 1851 (Ochsner & Mahorner, 1939), who introduced the hypodermic syringe, and opened new avenues of approach to the treatment of varicose veins.
It is interesting to note that Sir Everard Howe (Barrow, 1948), the brother-in-law of John Humter, was the first to observe that dilation of a vein made valves incompetent. However, the implications of this fact, together with the observations by John Hunter on venous circulation, have not been taken into full account by many of those who treat varicose veins.
In the early 1850s the treatment of varices by injection began to attract attention. Cassaignac (Babcock, 1935), and also Debout in 1853, used injections of perchloride of iron and reported some success. Desgranges used injections of iodotanin. Soule (Ochsner & Mahorner, 1939), noted the development of inflammation and suppuration following perchloride of iron injections, and advised the use of compression to prevent dilatation of the veins after injection. Muller (Ochsner & Mahorner, 1939) reported four cases successfully treated by injections of firon chloride in the 1860s, but Corbiu (Ochsner & Mahorner, 1939) reported severe phlebitis and sloughing following injections of persulphate of iron. A solution of iodotannin was used by Panas (Ochsner & Mahorner, 1939), who reported suppuration in both of his patients, and gangrene of the skin in one of them.
In 1876 Weinlechner (Ochsner & Mahorner, 1939), who reported the healing of a varicose ulcer by the injection, with iron perchloride, of varicose veins in the region of the ulcer. The popularity of the injection treatment was now accelerating, and Burroughs (1880) reported a series of sixty patients, with successful results in those who completed the treatment. Weber (Ochsner & Mahorner, 1939) reported using carbolic acid in one patient with success, and Stevenson (Ochsner & Mahorner, 1939) repeated this in eight cases. However, at the surgical congress of Lyon in 1894 (Ochsner & Mahorner, 1939), the injection treatment of varicose veins was much discussed, and it was finally decided, in view of the complications which all too frequently developed, that this treatment should be abandoned.
In 1904, Tavel reviewed the subject before the Congress of the Swiss Medical Association (McPheeters & Anderson, 1938) and advised the injection of 5% phenol solution into varicose segments of veins. This treatment was not widely accepted because of the severity of the reaction.
Schiassi (Babcock, 1935), in 1908, reported his results with high ligation and subsequent injection, and in 1913 he reported improvements of this method with further success. In 1911 Sicard (Babcock, 1935) of the Paris University, noted the obliteration of veins following injections with luargol solution. The reaction was too florid, and he changed to injecting sodium salicylate in 20%, 30% and 40% solutions. By 1919 Sicard had changed his technique again, this time using sodium carbonate. Kausche (Babcock, 1935), in 1917, introduced quinine and urethane. By 1930 sodium morrhuate had become popular and its use was advocated by Rogers & Winchester (1930). This popularity was increased by the mortality of operative procedures at that time.
However, popularity was followed by discredit, for in 1933 Faxon (1933) published the results of a follow-up survey of injection treatment, which showed a recurrence rate of 63%. Two years previously, Howard, Jackson & Mahon, (1931) had published a recurrence rate of 98% following injection treatment, and Ochsner & Mahorner (1939) reported a 60% recurrence rate. With the advance of surgical techniques and the discredit of injection therapy, treatment returned to the principles of Hippocrates, Galen and Aegineta.
However, most books written on the subject of treatment for varicose veins at that time still described various injection techniques and sclerosant substances. Ochsner & Mahorner (1939) injected varicosities with the patient standing up, and advocated compressing the limb by bandages for four to six weeks. Barrow (1948), who also injected the patient standing up, gave an injection into the varix, followed by bandaging, and gave no further injection until the first one had produced fibrosis of the varix. McPheeters & Anderson (1938) applied tourniquets before injecting, and advocated the necessity for immediate ambulation of the patient. They described better results following multiple injections.
Pratt (1949) stated that a tourniquet should not be used when injecting. He advocated the use of the fingers to diagnose the areas to be injected, and injected the patient standing up. Like McPheeters he advocated ambulation of the patient.
Linton, in 1938, was responsible for a major advance in the treatment of chronic venous insufficiency. He described in detail the anatomy of the performing veins of the lower leg, and an operative technique for their ligation when they became incompetent.
Many of the basic principles of treatment advocated in this monograph have been mentioned by other authors in the past: injection of a sclerosant, compression of the leg, ambulation of the patient, dietary measures. While Linton's operative approach to venous insufficiency was a logical one, those employing injection therapy appeared to have shown a singular lack of attention to the physiopathology of the underlying cause.
References
Adams, F. (1844), The Seven Books of Paulus Aegineta (Trans.), Vol. 2, London: Sydenham Soc.
Adams, F. (1886), Works of Hippocrates (Trans.), Vol. 2, New York: Wood.
Babcock, W. W. (1935), A Textbook of Surgery, 2nd Edition. Philadelphia: Saunders.
Barrow, D. (1948), The Clinical Management of Varicose Veins. New York: Hoeber.
Burroughs, H. (1880), Med. Press & Circ.29, 118.
Faxon, H. H. (1933), New England J. Med. 208, 353.
Franklin, K. J. (1937), A Monograph on Veins. Springfield: Thomas.
Harrison, F. H. (1929), Introduction to the History of Medicine, 4th Edition.
Philadelphia: W. B. Saunders Co.
Heister, L. (1968). A General System of Surgery, 8th Edition. London: Whiston and others.
Howard, N. J., Jackons, C. R. & Mahon, E. J. (1931), Arch. Surg. 22, 353.
Linton, R. R. (1938), Ann. Surg. 107, 582.
McPheeters, H. O. & Anderson, J. K. (1938), Injection Treatment of Varicose Veins. Philadelphia: Davis.
Ochsner, A. & Mahorner, H. (1939), Varicose Veins. St. Louis: Moresby.
Paget, S. (1910), Journeys in Divers Places, by Ambrose Paré (Trans.). New York: Collier.
Pratt, G. H. (1949), Surgical Management of Vascular Diseases. Philadelphia: Lea & Febiger.