Treatment of Varicose Veins in the Lower Limb. - SAMJ Archive by pengxuebo


									·S . A.                       -
          T YD >I« RI F V I R J
      GES EESK U SDE.                                  VARI COSE YEIXS IX THE LOWER LDIB.                                 [ D £ SE:\lB ER   'Z7 1941.   503

     (4) I t would appear, a t any rate be fore a state o f                         Treatment of Varicose Veins in the
-ce re bra l cede ma has developed , th at the pro gnosis                                     Lower Limb.
 a fte r ope ra t io n o n sub dura l hsemat om a is p robab ly
 ve ry good.                                                                        By   x . G,\ RIlE R,   B. Sc ." }>'I.B ., C II. B. (H..vxn ) ,
                                   BIB L I OGRAPHY .                                                   F .R. C.S . (E :-<G.) ,
                                                                                     Assis ta n t Cli nical Tut or, Un iversity of th e
:1    l1
      J u n rn ,         D.:      Crani o- Cereb ral    I nju ries :   Th eir
                                                                                                       Witsoat ersra lid .
        D iag no sis an d T rcat m cnt . NC7.C' Y o rk : o .rf ord
        J! edical P ub lica tions, 1938.                                        rI1HE fo llo wing t reatme nt is th at em ploy ed in th e
  C Sno dg ra ss , S. R . : Te xas S ta t e l o u rnal of Mc di-                    V arico se Vein and H rem orrhoid Cl inic attac hed
        cinc . l an. ., 1940.                                                   to D r. D auths surgica l un it a t the Ge ne ra l Ho sp ita l,
. 3 P ni ,  T. f. , Pu tnam, I. K. : E xp erim en tal                     Johanne sb urg .
       St udy of Pach ym e nin g itis luc m o rrhogica , f .                    CU. S S IF lCATIOX .
       .\ ' cru. an d At ent.. Dis ., 65, 260, 1927.                                  (i) Va ricosity o f t he g reat saphe no us vei n
  4 P ut nam , T . f ., and Custiing , H.:          C h ronic S ub -                      sys te m, ankle t o gro in .
       d u ra l H a:/IIa t oma . A rc h . S u rg., 11, 329, 1925.                    (ii) Va ricos ity o f th e great sa phe nous v ei n
                                                                                          sys tem, a nk le t o juncti on of -Io we r third
··s D a ndy. W . E . : S u bd ura l H onnaiom a , Pra cti ce of                            with upper tw o-thi rds o f t he thi gh (beca use
       S urg ery , by D ean L euiis ,                                                      a vein co nnect ing t he fem oral a nd g reat
  6 Tr o t te r. T . : B ri tish I o urnal of Su rg ery , p. 2 71 ,
                 V                                                                        sa phenous veins in t his locali ty is frequ ently
        V o l. 2, I9 l.:J. .                                                              pre sent an d va ricose) .
                                                                                    (iii) Va ricosity of th e g reat saphe no us ve in
  ; Ga rd n er, TV. f . : 'Traumati c S ub d u ral Hremat oma
                                                                                          svstern , ankle to knee .
           wit h Particula r R cjere ncc t o La ten t Lnt erual ,
                                                                                    (iv) Va ricosity of t he sma ll saphe no us vem
           A rc h, N eu rol . Ps clr., Dec ., 1936 .
                                                                                          sys te m.
 S    F razic r. C. H .: S urgi cal Mono g em ent o f Ch ro nic                      (v) Localise d varicosi ties (invo lving t he su per-
         S ub d ura l H « ma t oma, A n n. s vrs.. F cb ., 1935 .                         ficial lat e ra l or medial femo ra l veins, or a
 n Dandy ,          W. E.: Chro nic S ub d ura l H yd ro m a.                             tribu t a ry in the calf ) .
           P rac tice of S u rgery, b}' Dea n Lewis.                               (vi) F ine cuta neo us varices (" spider bursts        or
                                                                                          ,. rock burst s" of A me rican obse rve rs ).
 10   T ro tte r, W . : Th e S calp, Sk ull and B rai n : 11                       (vii) Va ricosi ties a socia ted with arte rio-veno us
         Sys tem of S urg ery , edite d by C. C. Ch o yc e,                               fist ulse.
J.l   Kcnnc dy, F ., and Wo rtis, S. B. : A w t e S ub d ural                     (viii) A diffuse hccmangiom atou s condition. gro ss
        ~ a: lIla to m a and A cu te E pi de rma l H em orrha gc .
         {                                                                                 dila tation of ve ins and a rt eries involving
       .» os., Gyllec., Ob st., Dec., 1936.                                               th e skin of th e whole lim b .
                                                                                1 XVE STI GATI O X O F T Il E PATIEI\T.
                                                                                   (A ) Hist o ry , with s pecia l refe ren ce to pre viou s
                                                                                " white leg ", or sym pto m s suggestive of pregn ancy.
       W e a re ind ebt ed to th e Goverlllll Plll Oo i eu.e of Decemher 5      uteri ne or ovarian tu mo urs (ma ligna nt ty pe s e speci -
'f or th e following list of military hospitals in the u ni on, wh ich
' will , we feel sure, he of consid era h le interest to our rparlers :         ally ). o r rec ta l g rowths. Unilate ra l varico sity may be
  Premier ~[in e , Sonderwater an d K affers kra al Camps , ~ I ilit a ry       th e pre enting sym ptom of ov a rian ca rcinoma o r of
 H osp ital. etc.; .Joh an nesbur g A rea Mi litury H osp it al. etc. :         ca rc inoma of th e rectum .
 P ot chefstroo m Ca mp M ilita ry H ospit a l, .etc . ; Yerecniging               rf an u lcer is present, e nquir ies should be m ad e
  Ca mp ~f il i ta ry H ospi tal, et c. ; Ha nd font cin Ca mp M ilita ry
  Hosp it al, et c.: P retoria City Defence H eadqua rters and                  about th e pr esence of ch ro nic tonsi llit is, diabetes
 W ond erb oorn Milita ry H osp it al, etc. : W at erk loof and Lyttelt on      mellitu s , syphilis , t ub erculosis . or post-ph lebitic
 Ca mps ~[ i l i t a ry H ospit al, et c.: Germist on Camp Milit a rv           ulce r (an ex t reme ly painfu l condition , a seq uel to a
  H ospital, et c. ; Benoni Ca mp M ilitary H ospital, et c. ; W el,
 gedacht (Springs) Ca mp Milita ry H osp it a l, etc .; E ast London
                                                                                previous phlegm asia alba dolen s).
 Ca mp Military H ospital , et c.; P ort E lizabeth Camp Milita ry                 ( B) E xaniinatiou, Thi s should includ e the tonsils
  H osp ital, et c.; La dy smit h Camp ~l i l i t a ry H osp it al, etc. ;      (for inf ection which may pe rpetuate an ulcer) . th e
 Go rdo ns nay Camp ~ [il itary H ospital , etc .: Qu eenstown Camr             a bdomen (fo r pelvic swe llings a nd g rowths ). and
  :-'f ilita rv H osp ital, et c.: \ Vit ba nk Ca mp Milit ary H ospit al,
 etc.; George Ca mp ~I i l i t a ry H osp it al , etc. ; Caro lina Camr
                                                                                inv estigat ion s of th e rect um a nd vagina.
  ~lil i t a l'Y H osp ita l, et c.; W ind hock Ca m p Military H osp ita l .      Tn th e pr e encc of a n ulc er. exa m ina tion of th e
 et c.: ~[ i d d e l b u rg Ca mp ~ lilitary H ospit nl, et('.: Durban and      uri ne for su gar sho uld not be omitted.
 Cla ir wood Ca mps M ilitary H ospit a l. etc . : Gr ah am stown Ca mp
 ~Iilitary H ospital , et c. : K im berl ey Cam p ~I ilitary Hosp ita l.        Exam ination o f the Lim b.
 et c. : Pi!'! Ret ie f Ca mp ~ f i l i t a ry H osp ital, etc.; Standerton        l ns pe ctio n :
 Ca mp ~[ i l i t a ry H osp ita l. etr-. : K roonstad Camp :' 1ilitary
 H ospital. etc . ; K owie Camp Military H ospit al, et c. : Nigel                      (i) Ulce r present-is it ne a r th e an kle? Is it
 Ca mp ~ l ilitary H osp ita l, etc. ; Oudtshoorn Camp ~l i l i ta rY                       ne a re r the kn ee? I n suc h a case investigate
 H ospital. etc . ; Bloemfontein, Bloemspruit and T ernpe Camps                             fo r lues and do a W a ssermann test.
 :\l ilita ry H osp ita l , et c. ; Cape Town ,             irnon stown and           (ii) Va ricose dermatitis present (b ro wn ind ura-
,Yynb!'r~ Camp s M ilita ry H osp ital , et c.; W alvis Bay Camp
;'[ilitary H ospital, ek. ; P iet erslmrg Ca mp ~r ilitary H ospita l,                      t io n of the skin). Va ricose" ecze m a"
-et c. : Ro berts H eigh ts A rea ~I i l i t a ry H ospita l, et c.                         present. This i a painful, pruritic. scaly
                                                                                                                        S.A . MEDICAL
504    DECEMB ER   27, 1941.]            VARI COSE VEIN       rx      T H E LOWER LDIB.                             [     J OU KSAL.

           condition affect ing the low er leg and foot.              situate in the saphenous vein immediately distal to
           If it complica te s an ulcer, pain becomes                 the sapheno-Iemoral junction (see Fig . 6).
           severe, esp ecially on walking, t houg h local                Where the main length of the vein in the thi g h
           discomfort and ' pruritus may ca use the                   is a pparent ly not varicose, yet a saphena va rix
           patient unt old mi sery, even in the absence               exists, operation (Tre ndelenburg 's ) shows : -
           of an ulcer. The causative agent is a n                       (a) That the tributaries normally entering t he
           Epiderm ophyton. Caref ul examination of                   great sa phenous vein in its highest portion are
           th e webs of the toes. and even of the                     markedly varicose .
           fing ers, will frequently disclose the presence               (b) That th e calibre of these ves sels is on a par
           of sca les or of macerat ed sk in. E arl y                 with, or frequently exceeds that of the parent vein
           relief of sympt om s is obt ain ed from local              (especially is such the case wh en the lateral an d
           inuncti on of W hitfield ' s ointment- ung .               medial superficial femoral veins are inv olved).
           co cois nucife rce-fo r ten minutes daily , cure              (c) That these enl arged vessels ente r th e saphena
           resultin g if t he inunction is applied for a              va rix.
           month.                                                        Clinical ex amina tion will further demonstrate
     (iii) Varicose veins. The distri bution acco rding           I   th at the se cha nnels a re the ma in links between the
           to the previ ou sly mentio ned classificati on is          saphen a varix and the below-knee varicose vei ns.
           noted , and the approx ima te diameter of the              In th e circumsta nces it is always advisable, in the
           g rea t sap hen ou s vein in th e thigh is ga uge d        presence of varicose veins in the calf, to investigate
           in centimet res. A diam et er of more than                 the foss a ova lis for the presence of a saphena va rix .
           half a cent imet re is indi cative of early vari-          If one is dis covered, it must be excised during the
           co sit y.   Inspection of th e groin should                perform anc e of a Trendelenburg 's operation, or
           never be omitte d; a distinct bu lg e of the               varicosity in the limb is sure t o recur.
           vein a t the fossa ovalis may be present                      Pe rcussion (mo dified Sclnuartz te st) : With the
           (m ore pronounced on coughing), even when              I   pati ent stan ding on a low table, the g rea t saphenous
           the rem ainder o f th e ve in is sca rcelv visi ble.       vein is comp ressed at the knee by the hand of an
           Especially may this be the ca se where vari-               assista nt, while the observer places flat fingers of
           cosity of the ve in in the th igh is unsuspected .         one ha nd ove r th e fossa ovalis (It inches below and
           This ve nous bu lge indi cat es defective func -           late ra l to th e pubic tubercle), and with the other t aps
           tion of th e highest saphenous valv e, and             I   the vein sma rt ly above the knee . A fluid imp ulse
           implies the necessity for Trend elenburg' s                felt by th e uppe r hand ind icates th at the vein is
           operation.                                                 varicose.
      (iv) Varicose pu dendal veins (labium majus of                     This test is of the greatest value .
           pregnant fem ale ) of varicocele and hzemor-
           rhoids may accom pany varicosity of the leg                TREATMENT .
           veins.                                                        Varices in th e first six groups only will be dis-
   Palpation : The g reat saphenous vein from ankle                   cussed. Those of Groups (vii) and (viii), including
to groin should be methodically palpated, especially                  varices from pregnancy or intrapelvic conditions , are
in the obese wh ere th e vein is not discernible to the               beyond the scope of this pa pe r.
na ked eye. It is surprising, in th e circumstances,                  Groups (i) and (ii).
how often a vein of more than 1 cm. in diameter is                       The t reatment recommended is Trendelenburg's
encountered. It is my experience that a g reat                        op erat ion, combined with t he intraveno us injection
saphenous vein with a diameter in the thigh of more                   of sclerosing fluid (resection injection of th e g reat
tha n i cm. is, especially if associat ed with lower leg              saphenous vein at the saphenous opening).            In
varicosities, undoubtedl y varicose itself.                           Group (ii) certain operators in addition divide an d
   I n certain Group (i) ca ses, the g reat saphenous                 ligate the vein opposite the knee, but I ha ve neve r
vein is varico se below the kn ee, t hough manifestly                 been convinced of the necessity for t his measure .
not involved in t he thi gh , acc ordin g t o the negative            Gro ups (iii) and (v) .
responses elicited by the usual in vestig ations (inspec-
                                                                         V ein s of t cm. or mo re in diameter are inj ected
tion , palpation, per cussion). If, however, the patient              with lit hium salicylate solution 2 c.c. , fo llowed by
is instructed to st and up and co ugh, a n examining              I   a few drops of distilled water, and then quinine
hand over th e fossa ov alis will discover two                        ur ethan e solut ion 2 C.C . A hypodermic need le No.
important facts : -                                                   16 calibre is employed (see treatment, Group (iv» .
   (i) That th e upp erm ost inch of the vein imm e-                     V eins smaller than t cm. in diam eter are inj ected
diately distends t o form a swelling which resembles                  with I to 2 C.C. o f et ha molin solution, acco rdin g to
an ac orn in size and shap e.                                         the len gth of vein to be sclerosed. Size 20 nee dle
   (ii) That a pronounced " thrill" is felt in this                   is recommended for this purpose.
sw elling.
   These facts demonstrat e the presence o f a saphena                Gro up (iv).
varix, i.e . a va ricos ity limited to the most proximal                 If th e sm all saphenous ve in in the poplit eal fossa
portion of th e vesse l, a nd indic ating the abs ence or             is t cm. or more in diameter, the onl y satisfactory
defective fun ction of th e all -important valve normally             treatment i res ection of the most proximal :2 inches
    ~EESKU=E .                        VARI COSE VEINS      rx       THE LOW ER LIMB.                  [ DESDIRER   27 1941.   505
  of the vein, afte r ligation and division of all                  whi ch period it is re-applied ea ch morning with
  tributaries ente rin g th is venous segment.            The       vigour. The band age encourag es cohesion of t he
  rem aining po rtion of the vein is oblite rated by th e           vessel walls, and the support it lends is a source of
  injection of sclerosing solutions (lithium salicylate             g re at comfort to the patient during th e acute sta g es
  30 pe r cent., and quinine urethane, st andard                    of the phlebitic process.
  so lution) . The procedure, which is performed under                 (vii) I njections should be repeat ed at weekly
  loc al anzest hesia and through a t ransverse popliteal           inte rvals t ill all veins have been satisfacto rily
  incisi on , in every respect duplicates T rendelenburg 's         obliterated. Good illumination (pre ferab ly daylight)
  operation.                                                    I   and sh aving of hair from th e lim b render veins mo re
      If the vein be less than t cm . in diameter, it is            ea sily discernible.
  obliterated by injection with ethamolin so lution 1               TRENDELENBURG ' S OPERATI O N :
  t o 2 c.c ., for I have disco vered t hat in the sm aller
                                                                       The obj ect of the operation is resecti on of the
  vessels, quin ine salicylate (result of interaction
                                                                    most proximal 2 inches of th e g rea t sap henous vein,
  between lithium salicylat e and qu inine urethane )
                                                                    after ligation and division of all tributar ies entering
 evo kes an inflammatory re action which t ransgresses              this venous se gment. The procedure. which can
  th e venous wall to involve the pe rivenous tissues,
                                                                    successfully be perfo rm ed under local infiltra ti on
  wit h the production of marked pain and raised,
                                                                    ansest hesia , is very commonly nec essa ry ; indeed,
 tender, pe rivenous swellings. In the larger veins,
                                                                    surprising ly so . Of 100 limb s examined, 43 required
 however, the scle rosing effect of quinine salicylate              operation .
 ha s been so succ essful that I have not been tempted                 ( 1) Pre-opera tiue Preparation: The pa tient is in-
 t o utilise any other agent for this purpose.
                                                                    structed to take a bath before th e operation , and to
      In the injection treatment of varicose veins, the             shave all pu bic hair and th at o f t he affected thigh
 following su g g estions, if adopted, will ensure maxi-            to below kn ee- level (shaving th e hair renders pain-
 mal thromboses with minimal discomfort to th e                     less the removal o f elastoplast from the ski n) . In
 pat ient : -                                                       stout wome n, a reddened moist area of inte r trigo is
      (i) Only one inj ect ion should be g iven per week ,          frequently pr esent in the cutaneous fol d at the g roin .
 and th at into the upp er portion of th e vein (i.e . nea r        This area should be tre at ed with methylated pirits
 t he knee), in order th at a maximum len gth of vessel         I   three or four times daily fo r seve ral days before
 should be involv ed from th e influenc e of gravity.               ope rat ion, to avo id infection of the incision .       In
      (ii) The needle should be introduced into a                   nervous pati ents, 3 g ra ins o f nembutal administe red
 dis tended vein. For this purpose it is advisa ble to              half an hou r be fo re ope ration as su res me nt al
 have the pat ient seated upon a couch or operating-            I   repose .
 t able with the leg hanging ove r the edge. How-                     (2) A rma m en tarium: The armame nta rium should
 ever, th e position of st anding on the couch is fre-              include t he follow ing:-
 qu en tly prefera ble, and ind eed well tole rated by most                (i) A stout pair of toothed dissecting fo rceps.
 pat ients. If slight faintness should develop, a                         (ii) A pair of non -t oothed dis secting force ps.
pledg et of antiseptic cotton-wool should be held                        (iii) A pair of Mayo sciss ors on th e flat.
again st t he puncture, whil e the patient is assisted                   (iv) Three pairs of H alstead 's strai g ht " mos-
into the supine position.                                                       quito " fo rcep s.
     (iii) The needle shou ld penetrat e the side of the                  (v) Two pairs of H alstead 's curved " m os-
vein. If intro duced in any other fash ion, it is likely                        quito " forcep s.
that both walls of th e vessel will be trans fixed and                   (vi) Three flat-bl aded retractors with curved
the solution deposited into the subcutaneous tissues.                           ends.
     (iv) T he "withdrawal " test (i.e . as piration of                 (vii) Two 5 c.c . Record sy ringes with ecc ent ric
blood into the sy rin g e) should be employed prior to                          noz zles . (These should be filled before
m aking the injection.          The fluid should be int ro -                   operation, on e with 3 c. c. of 30 per cent.
duc ed slowly. If the " twin" injection (lit hium and                          lithium sa licylate solution contai ning 1 per
quinin e solutions) is to be employed, th e lithium                            cent. of tutocaine, and th e other with 30
syringe is used first, th e needle left in th e vein                           per cent. qui nine ur ethane solution (Stan-
lum en, th e syringe detached and one carrying dis-                            dard). )
tilled wat er su bstituted ; afte r inject ion of a few               (viii) A 1 C.C. sy ringe filled with distilled water .
drops of this fluid, t he qui nine-be aring syring e is                  (ix) A smal l container of flavin e solution 1 10
attached to t he needle and its conten ts are injected.                      1,000.
     (v) The sit e o f inj ect ion is ste rilised beforeh and           (x) ~ curve d cannula about 5 inch es long (l
with a pled get of co tto n-wo ol wrung out of me thy-                       inch ex te rnal diam et er,"* inch internal
lat ed spirits, and pressu re exercised on the puncture                      diam et er) whi ch satisfactorily fits th e 5 c.c.
for a minute or tw o a fte r th e inje ction, to obv iate                    and 1 C. C . syringes.
perivenous escape of the scle ro sing so lut ion. Com-                 (x i) F ine curve d cutting needl es, fine silkworm -
pression of the site o f injecti on is essen t ial if the                    g ut o r " Kaldermic " suture, an d a nee dle-
dru g has been adm inistere d to t he st anding patient.                     holder.
     (vi) The lim b is firm ly bound from t oes t o knee              (xii) A st rip of adhesive felt 1 foot long by 2
with a 3-inch crap e bandage o f g ood quality, which                        inches broa d, a roll of elastoplast an d a 3i-
the patient is instructed to wea r for a week, during                        inch cr ape bandage of g ood qu ality.
                                                                                                                                                            S .A.
506    D l: CE)IBJ:R   zt , 1941. ]                                           VARICOSE YE l l'   rx   THE LOWE R LDIll.                                 [
                                                                                                                                                                  M EDICAL
                                                                                                                                                              J OU RNAL.

   (3) A ssistan ts : It is imperative that th e surgeon                                              lon g (-t inches in th e obese) placed pa rallel t o the
should have two assistants, one placed by his side.                                                   inguinal lig ame nt (i.e . passing do wn wa rds and
th e other facing him ac ro ss th e patient's body.                                                   inwards), a nd situat e at a point along the surface
   (4) S urfa ce Markill g of th e Great Saphen ou s Vei n                                            m arking of the vein, I inch below t he sit e of th e
in its Proximal S ix fil ch es : The surfac e marking to                                              sapheno-femoral opening. H alf the incision sh ould
be described is one th at I have found of inestimabl e                                                lie lat eral a nd half m edi al to th e surface m arking o f
value as a guide t o the subj acent position of th e                                                  the vein.
vein (see Fig. I) . As a p reliminary, the site of th e                                                   (5) A na st lt csia of th e Operatioll A rea: Infiltra-
sa phe no-fem o ra l junction (in th e fos sa ova lis) is                                             tion of the operation area with I pe r cen t. novocain
establishe d by m arking with a str ip of flavine g au ze,                                            solution without ad renalin is effected by u sin g a 20
a point I ! inc hes below and lat eral to the pu bic                                                  C.C. Record syringe , to which is a ttach ed a fine
t ubercle, so that th e line fr om tu bercle to foramen                                               needle 3 inches in leng t h .          A drenalin so lution is
s ub tends an angle of 300 to a line running t ran s-                                                 om itt ed o n acco unt of the pall or, palpitation and
verse ly through th e pubic bon es. The junction o f                                                  g ene ra l disco m fo rt it s adm inistr ation in du ces in th e
t he upper third with th e low er tw o-thirds of th e                                                 pat ient. Certa in regions ca ll fo r spec ial a tte ntion
                                                                                                      and infilt rat io n:-
                                                                                                             (i) The o ute r ex t re mity o f t he incision (becaus e
                                                                                                                 th e nerve su pply ente rs th e operat ion field
                              S ur f acQ            ",,,           or    the                               Ianwise fro m above an d laterally).
                                   GTeot Sap~ous Ve'/..                                                    (ii) The region of the fossa ovalis, where a poo l
                                                                                                                 of -t C.c. of novocain shou ld be m ad e.
                                                                                                          (iii) A point mid way between (i) and (ii) where
                       -   - - - - - - ---           -.                                                          the lurnbo-inguinal nerve becomes su pe rficia l.
                             ~< o~                  ,,'       1't.                                         (iv) T he region between the upper lip of t he
                              \QC 'S ~
                                           ,/         \
                                                          \                                                      wound and the inguinal ligam ent (in orde r
                              k,,~ of       S>yll';                                                              t hat th orough painless retraction of this

                                f"qo-'S"    ve.'Q             \
                                                                                                                 up pe r lip may be rende red possible ) .
                                                \                    \
                                                                                                          The ope ra tio n area is infiltrated from skin to deep
                                                                                                      fascia, 20 c.c , o f I per cent. novocain sol ut ion being
                                                                                                      a deq ua te. In fat people 30 C.c. is advisa ble .
                                                                                                          (6 ) Exp os ure of t he U pper Three l n ch es of th e
                                                                                                      Vein : The skin is divided with a sha rp sca lpel along
                                                                                                      the line pre vious ly m arked o ut by flavine, and small
                                                                                                      Poirier fo rce ps applie d, tw o to the upp er third of the
                                                                                                      wo und (co nt ro lled by on e hand of o ne assistan t),
                                                                                                      a nd tw o to the lowe r lip .o f th e wo und (c ont rolled
                                                                                                      hy one hand o f the o t he r as sista nt) . The incision is
                                                                                                      dee pene d with long cu rved Mayo scissors, and small
                                                                                                      a rte ry fo rce ps applie d t o three bleedin g p o int s (the
                                                                                                      su pe rficial external pudendal, the superficial epi-
                                                                                                      gast ric, and supe rficia l circum flex iliac a rte ries). The
                                                                                                      bleeding' point s a re lig at ed with 00 ch ro m ic catgut
                                           F IG.      1.                                              and th e wo und further deepened thro ugh the
                                                                                                      cedema t ous su bcuta ne ous fat down to t he shining
in ner a spe ct of t he thi gh i th en marked with                                                    fascia lata , upon which th e vein is found (goo d
flavine, and this poin t joined to th e position of th e                                              retraction , s ponging and goo d lighting are esse ntial
saphe no-ferno ra l ope ning by a line coursing upwards                                               if this st ag e of t he o p craiio n is to pr ogress sm oothly
and o ut wa rds . T his second line is a mo st reli able                                              an d rapidly). The vein is seen dimly blue through
surface m arking of th e upper 6 inch e of th e g reat                                                its sto ut sheat h o f a dvent it ia . At this sta g e it is
sa phe no us vein , a nd is of va lue es pec ially in t he                                            impo rta nt t o use fiat-blad ed , cu rv ed r et ra cto rs in
obese, in whom fiftee n t o t wen ty minutes m ay be                                                  o r de r t hat t he depths of th e wound may beco m e
fru it les sly expended in search for t he vein, unles                                                plainly vis ibl e . T he adve ntitia is seized with non-
a suitable g uide be avai lable. It is important t o note                                             t oothed diss ecting forcep s, a nd open ed in the length
that in su ch patient s th e sa pheno -femo ra l juncti on                                            o f th e vess el for ab o ut 2 cm . • Mayo scisso rs cur ved
m ay lie more tha n 3 inc hes dee p to skin lev el , while                                            on the flat being the most suit able instrument for
2 inc hes distally th e vessel is conside rably nearer t he                                           th is purpose.         By blunt dissecti on with these
surface .      This inf ormation has stim ulate d M e-                                                sc i sor , o r wit h m all curve d blunt-pointed " mos -
P heeter , t he not ed America n urgeon , to ex pose                                                  q uito .. fo rce ps . t he ye sel is fre ed from a len gth of
th e vein a n inch dist ally to th e sapheno -fem ora l ju nc-                                        its ' heath . M an ipulati ons sho uld be g en tle, fo r,
tion. a nd then strip it up t ow ards th at junction.                                                 thoug-h the venous wall in ca se s of va r icosity is
P erformed this way , th e operati on is conside rably                                                usuall y thick . it is on oc casions , how ever. rather
ea ier. The skin incision , the ref ore , is o ne 3 inches                                            thin and del icat e , a nd m ay be only t oo ea sily
8 .A.T YDS KR U' V IR ]
  G ENEESKtfND E.                        VARI COSE VEINS IN T H E LOWER LBW.                               [ D ES E) IBER   zt 1941.   507

rupt ured . With the aid of an a neury sm nee dle , or            sho uld be gent ly but firml y retracted, more and more
be tte r still a pair of curved " m osq uit o" fo rceps,          fat being co nt r olled by the ret ract ors a s the dissec-
the vein is encircle d distally with a 00 chromic ca t -          tion deepens towards the saphenous ope ning .
gut ligature, tied with a triple knot, the fre e ends             Co rrec t disp osition of the sup e r ior retractor s
be ing 4 inches in len gth and clip ped at their                  enhances the ex posure of t he upper reaches of the
te rm ina tions by a pair of a rt e ry fo rceps (see Fi g . 2).   great saphenous vein, and is t hus vital t o the success
                                                                  o f the operatio n (see F ig . 3). T he surg eon should
                                                                  with one hand g rasp the hzemostat ca rrying the
                                                                  venous stump , and g ently d raw the latter up wards
                                                                  and out of th e wound, thus disp laying the tributarie s
                                                                  wh ich enter the ve in in this region . T he progress
                                                                  tow ards the fos sa ovalis is facilitated by passing a
                                                                  fi nge r pr oximally a lo ng the posterio r as pect of t he
                                                                  ve no us stum p . This ma noeuvr e is q uite sa fe, since
                                                                  the loca l t ributaries enter t he saphenous vein , not
                                                                  on it s posterior, but ra t her on its anterior, lateral
                                                                  and medial aspect s . M o re and more retraction will
                                                                  be necessary as a g rea te r length of th e ve nous stump
                                                                  is displayed. Tributarie s are th e supe rficial external
                                                                  pudenda l, th e supe rficial epigast ric . and the
                                                                  super ficia l circumflex iliac veins , wh ich enter th e

                             FIG.   2.

H alf a n inch proxim al to this ligature, a pai r o f
strong a rt e ry forceps is placed upon the vessel ,
which is divided by scissors mi dway between the
forceps and the lig a ture . The catgut lig ature
should be vis ible be tween the lip of the skin
incision (no t hidd en be neath the low er portion of
the wound) , thus facilitatin g t he app lica tion of a
sec ond, more distal and important lig at ure du rin g a                                   I'll ; .   3.
late r sta g e in the ope ra ti o n .
  (7) Exp osure of th e S aphena-fem oral ] UlICti01I             g reat sa phenous an te riorly ; th e supe r ficia l lateral
and Ligation of T ributaries : This part of the opera-            femoral vein, which enters on its la teral aspect , and
tion is simplified by the us e of th re e flat-bladed ,           th e   superficia l medi al     femora l vein,        which
cu rv ed retractor s placed thuswise : one below th e             occasionally is present , when           it j oins the
venous stump , t he others above t he stump, one on               g reat 'sapheno us on its medi al a spect .             The
either side of the ve in.    kin and subcutaneo us fat            superficia l lateral fem ora l and superficial medial
                                                                                                                         S.A.   :'lEDIC.' L
508    DECEMBER   27, 1941. ]           YARI COSE VEINS IX TH E LOWER LDIB.                                          [            .
                                                                                                                          J OU RS"' L.

 fem oral veins are on occasions of such a size that              ! (As sista nt   B auto matically ti ghten s th e lo ose lig a-
they a re easily mistak en fo r the g re at sap henous            I   ture.) The lithium solution is slo wly injecte d when
vein, an d lig ated and resect ed in its stead, a mis-                the pati en t may co mp lain o f spas m od ic pain do wn
 fo rtu ne which p redisposes to early recu r renc e of               th e leg to th e ankle. The em ptie d sy ringe is quickly
va ricosity. The small venous radicl es are best                      repl aced by one bea ring distilled wat er . whe reof !
iso lated by blunt dissection with curved H alstead                   C.c. is inject ed to flush the cannula. This sy ringe is
,. mosquito" fo rceps (see Fig . 3), t hen lig ated with              then repl aced by t hat bea ring the quinine solution,
00 ch ro mi c cat g ut, so that on e lig ature is placed              which is simi larly inject ed . A fte r fur ther int roduc-
clos e to th e saphenous stump a nd the othe r t inch                 t ion of a t C.c. of distilled wate r, the cannula is wit h-
awa y. The ven ules a re divided by sciss ors midway                  dr awn from th e ve in and the incom plet ely ti ed lig a-
bet wee n both lig atu re s. In some cases, tributaries               ture complet ed with a triple kn ot . A similar lig at ur e
ente r the saphenous vein in the depth of th e foss a                 is applied nearer the cut end o f th e vein, for by
ova lis, when g reat care is need ed in executing double              double ligati on chem ical solut ions a re p re vent ed
lig ation and divi sion o f the venules. Assistanc e in
 ex posu re m ay o fte n be gaine d by dividing with
Mayo 's scissors th e upper an d low er co rn ua , and
the lateral border o f the for am en . a ll occasions,
t hese tributaries ent er the femo ra l vein it self-
lig ation is then a difficult matter unless gen erous
division of th e walls o f th e fo ram en is effecte d . A ll
exc ellent guide t o the low er bo rder of th e fo ram en
is the deep ex te rna l pudendal a rte ry, which a rises
fro m th e femoral arte ry and curves m edi ally be hind
th e g re at sa phe nous vein alon g this border of the           i
fo ram en. The a r te ry will fr equ ently be enco untere d
in th is position , th ou g h occasio nally it lies anter iorly
t o th e vein .       Wh en eve ry tri butary has bee n
sa tisfacto rily lig at ed and divided, a cat gut lig ature
tied by a triple kn ot is placed up on the sa phe nous
stump at its juncti on with th e fem oral ve in. The free
ends of this lig ature sho uld be at least t inch lon g .
Af ter a similar lig ature has bee n applied i inch dis-
tally, th e bulk of th e stump is resected, leavin g i
inch protrudin g beyo nd the dist al lig ature .           The
double ligature a bo ut th e venous stum p ens ure s th e
prevention of reacti on ary hsernorrhage.
    (8) I nj ection of tlie distal cut end of th e saph enous
u ein : The retract ors a re removed and three st ra ig ht
" m osquit o" forceps applied at equidist ant points on
th e cut dist al end o f th e v ein, which is th en drawn
out of th e w ound. The surgeon, afte r releg ating t o
the assista nt opposite him (assist ant A) th e vein
now unde r t raction , pack s the wound with a moist
gauze swab a nd applies a lig ature loosely about
the vessel, so th at th e lo op of thi s lig ature is dist al
to the kn ott ed on e applied ea rlier in the operation .
a nd the ends lon g and free. These fr ee ends a re
handed over t o th e cont ro l of th e assista nt bv th e
sur g eon' s sid e (a ss istant B). The ca nn ula is 'fitted                                   F IG. 4.
to the syrin ge bea r ing 3 C.c . of lithium sa licylate
solution, a nd th e syringes con ta ining distill ed wat er           from regurgitatin g and so iling th e wound.            Anv
a nd quinine uret han e placed in a handy position                    solut ion that accidenta lly esc a pes from th e can nula
nearby. Th e surge on then ta kes up a sca lpel in his                is ab sorbed by the gauze swab (it is important to
left hand (cutt ing edge upw ards), and int ro duce s the             prevent contamination of th e wound by quinine
ca nnula tip into th e lum en of th e cut sa phenous vein             salicyla te, which produces a violent inflammat or y
with th e right hand (see F ig . 4), ha ving pr ev iously             reaction in perivenous tissu es). The wou nd is no w
 inst ruc ted ass istant B to t ig hte n the loose lig a-             g ently clean sed with aline and then with flavine
ture wh en the can nula has slipped past the                          solut ion I in 1, 000 , whereaf ter th e sk in ma rgi ns
latter and down t he vein.              T he kn otted lig a-          a re approxim at ed by vertical mattress sutures of fine
ture is no w di vided wit h a br isk upwa rd s                        silkworm-g ut or kaldermic .        Fine curved cutting
mov em en t o f the sca lpe l, and th e cannula by                    ne edles and a needl e holder facilit at e coa pta tion of
ge ntle pressure slid down t he lum en o f th e ve in                 t he wound margins, th e result, a week lat er (when
unti l 4 to 5 in ch es have dis appea red fr om view .                sut ures are removed ) , being a fine hai r-line sca r.
  GEl\LESK U YDE .                                            YARI COSE YEIX S IN THE LOWER LDIB.                                              [ D ES D 1RER            27 1941.   509
   (9) Th e Dress ing: A gauze pad 4 inch es lon g by 2                            ob lite rated .  Tributaries not th ro mbosed a re th en
inch es wide wrung out of flavine so lution I in 1,000                             injected , usin g a fine ne edle, N o. 16 ca libre, with
is placed oy er th e inci sion and covered with a st erile                         th e lithium-distill ed water-quini ne se quence. or et ha-
cott on-wool pad of similar dim en sions. The dr es-                               molin solution a nd a N o . 2 0 nee dle, depending upon
sin g is m aintained in position by a st r ip o f elas t oplas t                   the pres enc e o f larg e or sma ll venous radi cles.
3 inches wide which ex te nds from a point sev era l                               Obliteration in the bulk of case s is em inently satis-
                                                                                   factory, however, afte r th e primary inject ion .          It
                          ~j ":7
                             •   ~O:-
                                                                                   is advisa ble to instruct th e pati ent in the correct
                                                                                   applica tion of the bandag e , st ress ing (i) co mme nc e-
                           :::::~:::":"'': :':
                                                                                   m ent a t th e ankle , where two figures of 8 sh ould be
                                                     .<'>._   I                    em ploye d, and (ii) progress of th e ba nda g e to ward
                                                     "        ~                    the kn ee, employin g as mu ch tensio n as ca n be

                                        ufJ~                                       t olerated. The crape banda g e is wo rn fo r at least
                                                                                   t hree weeks.
                                                                                      Complications of I n j ection T h erapy : ( I) Localised
                                                                                   periven ou s inflammatory a r eas, du e t o an ex cessive
                                                                                   phlebitic reaction, occasionally app ea r in th e calf or
                                                                                   thigh followin g th e use of m ode rat e amo unt s of
                                                                               I   lithium salicylate and quinine ureth an e . The inflam-
                                                                                   matory process is bes t treated by applicatio n o f
                                                                                   g lycerine ichthyol t ogether with t he support of a
                                                                                   crape bandage.          Bed rest may be ne ces sa ry fo r
                                                                               I   tw enty-fou r t o fo rt y-eight hours. The complicati on
                                                                                   usually re so lves sati s factorily a fte r sev eral day s.
                                                                                      (2) Chem ical ulcer follo ws lea ka g e of lithium o r
                                                                                   quinine solutions fro m a vei n pun cture, or inad-
                                                                                   vertent pe riv en o us injecti on o f th ese chem ica ls.
                                        F IG.   5.                                 The latter m isfo rtu ne ca n be avo ided by use o f t he
                                                                                   " withd raw al test ". The ulce r presents a ,. punched -
inches lat eral t o th e ant erior supe rior iliac spi ne                          out " appea ra nce a nd is pa inf u l fo r se ve ra l days
downwards and inw ards acros s th e fro nt of th e                                 a fter its inception . It is best t reat ed by firm
dre ssing, th en upwards a nd outwards a long the back                         I   bandaging with elastoplas t , wh en hea ling slowly
of th e thi gh , a nd thus on to th e fr on t of the abdomen                       occurs.
(see Fig. 5). W hen sec ured in thi s way. the dressing
remains in posit ion for a week. th ou g h the pati ent
cont inues abo ut his or her dai ly r outine. T he
remainder of th e saphenous yein 'in th e thig h is
obliterat ed by comp res sion with a dhesive felt
and ela stoplast. A st r ip of th is felt 8 to I2 inches
long and 2 inch es wide is plac ed accura tely over th e
vein, which is alrea dy pa lpable as a firm co rd (owing
to venous spasm). Th e felt is m ain tain ed in po sition
fo r three weeks by st r ips of e las to plast whic h
encircle the thigh from th e wound dr essin g a bov e to
the knee below. T he suppo rt of th e felt and
elast oplast is m ost com for ting t o t he patient du r ing
the acute stage of chem ical phl ebiti s, while it
encourag es venous o blit e ration. The leg fro m ankle
to knee is no w enc ased in a 3-inch crape bandag e
a pplied under pres sure .        A banda g e is oi g rea ter
ut ility th an elasto plast, since the form er is eas ilv
rem oved after a week to permit o f atte nt io n t o an ,"
                                                                                                    \J pPe A.     2rtJUo€s                    ~. .. '"~ ..-..ou,   ~N
tributa ries not o bliterated by th e prima ry inj ection:                                                                       Of

   ( IQ) A fte r~treat11l.ent : The pati ent is not put t o                                         ~"          n-""@.a.JO,)l   '1&ilo A u.    O l'Cl';, l O.

bed ; rather IS wal king en coura ged in the immedi ate                                                                FIG. 6.
po st-opera tive peri od .       M ost patients a re o nlv
slig htly incomm od ed a nd a re able to continue at                                  T he clini c. wh ose work is devote d to the treat "
wor k. A few in whom th e phl e bitic reactio n i                                  ment of hremorrh oid s a nd va rico se veins, was
seve re, find r est in bed necessary fo r t wenty-fou r                            initiat ed in Decem ber . ' 939. From t hat date to t he
to forty-ei g ht ho urs , and become am bulant there-                          I   end of Xla rch, ' 94 1, 50 ca ses of varicose vein s were
a fter . Sutures a re removed afte r a week . wh en th e                           treated co m prising : Males 28 (bot h leg s, 19; single
whole of the g rea t sapheno us system fro m z roin t o                            leg- right , 3: left , 6). F em a les 22 (both legs, IQ:
ankle, including tri bu tari es, is "usua lly fOt1l~d t o be                       single leg- right , 7: left, s). Europea ns subjected
                                                                                                                              S .A. MEDICAL
510      D ECE:\IB ER   '2:7, 1941.]           VARICOSE VEINS IN THE LOWER LDIB.                                          [    J OUR NAL .

 to Trendelenburg 's op eration (Groups (i) and (ii) ) :                                Obituary.
 Both legs-males, 10 (i.e. 2 0 operations) ; females, 2
(i.e. 4 ope ra tions) . O ne leg-males, I I; females , 8.                          DR. A. F . ST E YT LER.
Total, 43 operations. Private patients subjected t o
Trendelenburg's operation, 11 lower limbs. Native 'rl" lIE deat h occurred on Decem ber 3 of Dr . Al ice Felicite
patients subjected to Trendelenburg's operation, 2           -l. St eytler , of The Red House, Harfield Road, Kenilworth.
low er limbs. Grand total, S6 operations.                    Dr . St eytle r was th e younger daughter of Mrs . H. P . Goldman
    Cas es requiring but refusing the operation, 2. and the late Mr. Alfred Goldman, and a sister of Mrs. F.
 Cas es with a history of previous " white leg ", I         Jouber t , wife of the Administrator of the Cape. She was
                                                            born at Graaff- R einet and ed ucated at Cape Town and at
(not suita ble for operation). Cases subjected t o re- U niversity College H ospital, London, wh ere she took her
sec tion lig ation of the sm all saphenous vein in the M.R. C.S . Eng. , L .R.C.P. Lond., in 1922. On her return to
popl iteal fossa, 2.                                        South Africa she practised for several years at the Fever and
    Associate d path ologic condition : Most patients of anasthet ics,H ospitals, Johannesburg, as one of t he anrest het ist s
                                                            Child ren's
                                                                            and for some years acted
                                                                                                        where she specialised in
Gro ups (i) to (iv) suffered from pes planus, while the of t he N ew Somerset H ospital. Her failing healt h compelled
feet we re cyanosed and perspired excessively.              her to relin quis h her hospital appoint ment, and for t he last six
Varicose ulcers over an inch in length occurred in year s pr eceding her death she was an invalid. After her
                                                            mar riage to Mr . C. G. St eytler she settled in Cap e Town.
four patients of Groups (i) and (ii). A further case
                                                               She leaves a hu sband an d t wo children, to whom we exp ress
(refer re d fr om another su rgical unit for persistence our deep sympathy.
of small ulce rs desp ite vein obliteration) was dis-
covered to be suffering fr om erythrocyanosis
fri gid a . I n two fema le patients an Epidermophyton                             DR. A. W . SAN DE RS .
in fecti on wa s superimposed-on a va ricose derma-
                                                                                an d unexpected death of Dr. Alf red WiJliam
t itis in one cas e and on a va ricos e ulcer in the 'T ,H E sudden announce d last month fro m P retoria , came as
                                                                    Sand ers,
other. As mentioned previously, early relief is a shock to his manv fr iends in t he U nion.
accorded by th e ex hibit ion of Whitfield's ointment.         Dr. Sanders recei"ved hi s medi cal edu cat ion at St . Mary' s
The ulcer, who se diam eter ex ceeded 2 inch es, healed H ospital, Lond on, whe re he had a disti nguished career as a
                                                            st udent . H e t ook his E ngli sh Conjo int in 1895, an d his London
within six weeks foll owing Trendelenburg 's opera- l\I.B. in the following year, having alr ead y won t he Gold
tion (the patient being constantly amb ulant, and at Medal for Anatomy in his I nt er mediate M.B. After holding
wor k). I n one case the Epidermophyton infection th e usua l hospital a ppointments at St. Mary's and at the
was ass ocia te d with an elepha ntiasis of the foot. Chi ld ren's H ospital, Great Ormond Street, he was appoin ted
A fter obliteration of the veins, and t reatme nt of the SeniorheDemonstratorst in Anatomy at his old school,niaorpost tha t
                                                            was t      immed iate epping-stone to one on th e ju           surgical
infection, the size of the foo t dwindled.                  staff. In 1898 he took hi s Lond on M. D. wit h honour s, and
    A few che mical ulcers developed du ring the early t he next year his F .R .C.S. En glan d, for his leanings were
period of the clinic's existence . They resulted from toward s sur gery, a sp ecia lity in which he was later on to
t he use of lithium and quinine solutions in the . di stinguish him self . Was a tCivil Surgeon, andarcam e to out he
                                                            volnnt eered for service
                                                                                        hen he Anglo- Boer W         broke
obliterat ion o f veins o f sm all calibre . Since the sub- Africa, where he was to spen d the strenuous, act ive life t hat he
st itution of ethamolin , however, ulcers have not led for forty-one more years. Aft er t he war he set tle d at
app eared.                                                  Pretori a, and rapidly won a large practice. F r om the beginning
                                                                   he specialised in surgery, and his sk ill and experience were
                              BIBLIOGRAPHY ·                       quick ly recognised by his colleagues as well as by his patie nts.
                                                                   H e was elected a member of the T r an svaal Medical Council
( I ) Dodd, H ., and Oldham, J. B. : Lancet, Jul y 6th ,          an d served on that body until, in 1929, he was elected a
       1940 . Surgical Treatment of Varico s e V eins .           member of the South African Medical Council, on which he
(2) H arv ey ,     S .: P os t-Graduate Surgery .       T he       sat up to t he t ime of his death. H e took an active part in the
       I nj ection Trea tment of Varic ose Veins . M edical       wor k of the B.l\l.A. and of our Association, and was elected
                                                                  to t he hi ghest posts in his Bra nch an d in several Medical
       Publications Ltd., L ondon, 1939.                           Congresses in wh ich he took part.
(3)   H eller, R . E. : Surgery, Gyn ecology and                      Dr . Sanders was a qui et, culture d gentleman, of strong and
       Obstetrics, D ecember, 1940. Path olo gical P hys i-       incisive chara cter, whose opinio n car r ied great weight because
       olo gy of V aricose V eins.                                it was never exp resse d un til aft er careful cons ider at ion of all
(4)   H oma ns , J . : Cir culat ory Diseas es of th e            aspects. 11is gentleness and great courtesy were among his
                                                                  chie f characterist ics, an d endea re d him to hi s patients, who
      E x t rem ities . The Mii cmillan Co., New York,            looked upon hi m as a perso nal friend on whose interest and
       1939·                                                      loyal ty th ey could fir mly count. Although in his later years
(5)   Mcl'lie eters, H. 0., and A nderso n , J. K.: Injec-        he confined himself to his special ity, su rgery, he rem ained the
      ti on Treatment of V aricose V eins and H amor-             idea l fa mily practitioner, whose rela t ions with his patients
                                                                  wer e personal alm ost as much as t hey were profe ssional. The
      rh oids ,     F. A . Davis Company, Philadelphia,           T alm ud ic imputation against the .. best physician " , temp era-
       1939·                                                      mentally incapable of at ta ining bliss, could never be brought
(6)   Stalker, L. K. , and H eyerdale , W . W .: Surgery ,        agai nst him , for his sense of r esponsi bil ity to those un der his
       Gy necolog y and O bstetrics, December, 1940.              care was a gui ding principle with him. In professional debate
                                                                  he was luci d, and could draw upon a vast experience tha t
      Factors in the R ecurren ce of V arico sities follow-       gave to his cont ribut ions a peculiarly convincing qual it y by
      ing Treatment.                                              it s const ruct ive reasoning and its clear-cut di scr imi na-
(7)   Wright, A . D. : B.MJ ., A pril zo th , 1940. T reat-       t ion between point s that mat tered an d tho se t hat could be
                                                                  ignored. H e was rarely ind uced to put pen to paper, and his
      m ent of V aricos e Veins.                                  cont r ibutions t o our medica l jour nal s were fe w, but were all
(8)   Wright , A . D.: B .MJ. , A pril 27t h, 1940. Compli-       ad mirable summar ies of t he su bjects with which he dealt. As
      cations of Varic ose Ve ins .                               a surgeon he was in the first ran k, for he had a fine ju dgment ,

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