VARICOSE ULCERS.

THEIR TREATMENT BY ESMARCH'S BANDAGE.

BY 0. B. CAMPBELL, M. D., OF OVID.

GENTLEMEN:-In the bginning of this paper I desire to call your attention for a few moments to the pathological condition of the veins in this affection, that we may more fully appreciate the great benefit to be derived from pressure in these cases.

The veins are simply dilated in some cases, but usually the dilatation is accompanied by attenuation of the walls of the veins; the transverse fibres of the middle coat become separated in places and the inner coat pressing through these openings forms irregular projections, which are especially liable to occur in the vicinity of the valves, which become thinned, stretched and torn asunder, affording little support to the column of blood in the vessel. This condition is soon followed by distention of the small cutaneous veins, producing serous infiltration of the skin, followed by cellular infiltration and thickening, and eventually by suppuration and disintegration. Thus we have this form of ulcers directly produced by distention and congestion.

It has been my fortune to have quite an extensive experience, for a local practitioner, in this class of ulcers. Since 1875 I have treated about thirty cases, a few of which I shall report in this paper.

Case 1.-Was called to see Mrs. T. F., aged sixty-seven, whom I found suffering excessive pain arising from varicose ulcers; administered morphine hypodermically, and when pain had ceased proceeded to examine the ulcers. Upon the right limb I found three quite extensive and deep ulcers, two upon the inner and one upon the outer surface of the limb. There was also a constant desquamation of the cuticle, attended by serous discharge, extending around the entire limb from the malleoli to the junction of the middle and upper thirds of the leg; the tissues were much infiltrated and the veins varicosed up to the saphenous opening. The left limb was in a similar condition, except the ulcers, which were smaller and but two in

number, situated just above the inner malleolus. Patient stated these ulcers began forty-five years before, had often bled profusely, and of late she was wearing out from excessive pain and hemorrhage. On the following day I applied a fly blister to the ulcers, which was left on thirteen hours, and on being removed was followed by an application of glycerine and a bandage evenly applied extending from the toes to the knee joint. The treatment from this time consisted in the use of the red wash and bandaging until February 20th, when the ulcers were healed, elastic stockings ordered and patient discharged. I saw this patient a short time since and found her enjoying perfect health and has had no trouble with her limbs for the past three years.

Case 2.-Mrs. J. T., aged fifty, had been troubled for fifteen years with varicose ulcers on the right limb. At this time she was dragging her limb about in a chair to prevent the pain that occurred from pressure upon the nerves when the limb was allowed to hang down. I applied a blister and followed with a bandage, under which the ulcer improved rapidly. An elastic stocking was applied and the patient discharged.

Case 3.-W. W., male, aged thirty-four, consulted me July 29th, 1876, with the following history: Several years before he had an oblique fracture of both bones of the leg at the junction of their middle and upper thirds, which had resulted in marked deformity. Soon after the fracture united an ulcer appeared which had troubled the patient nearly ever since. Upon examination I found an ulcer two inches in length by one in width upon the anterior surface of the limb, over the site of the old fracture. This patient had been treated for this ulcer in the hospital at Ann Arbor in 1875, where it had been healed in a few weeks by the application of a fly blister, followed by the red wash. The ulcer had remained healed until the following spring, after which the patient had begun active labor on a farm, when the ulcer broke out as bad as before. I immediately suspected this ulcer arose from some mechanical cause and upon examining found some small varicosed veins just below the knee. I then applied a bandage and ordered an elastic stocking, which came in two days, when I removed the bandage and directed the patient to wear the stocking. He returned home and the next week began work in the harvest field; three weeks after he returned to my office with the ulcer healed. In this case the ulcer healed from pressure alone, under the most unfavorable circumstances, without the application of any medicine to stimulate healthy granulation. Case 4.--Mr. A. B., aged forty-five, consulted me November

21, 1877. History as follows: About fourteen years before the patient had typhoid fever, which, as near as I can learn, was followed by an attack of phlebitis, and finally by varicocity of the saphenous veins; the limbs were much swollen and edematous with three ulcers upon the right and one upon the left limb. This patient suffered intense pain and said he had come to either have his limbs cured or cut off, as he could bear it no longer. I directed him to apply a fly blister that night, which was left on until morning, when it was removed and the limb firmly bandaged. All pain ceased from this time, and December 13th the ulcers were healed, elastic stockings applied and patient dismissed, who said his limbs felt perfectly well and he had gained fourteen pounds while under treatment.

The four cases I have here reported may be taken as specimens, and embrace essentially the principles carried out in all the cases occurring in my practice. In no case have I been disappointed in my expectations, and I have learned to feel as confident of success when I apply an Esmarch's bandage in a case of varicose ulcer as when I prescribe twenty grains of quinine in intermittent fever, and that, too, without any risk to the patient, whereas the various attempts to obtain a radical cure of this affection by producing obliteration of the veins over a certain portion of the limb has led to evils and dangers out of proportion to the affection itself; besides these operations always fail in effecting a radical cure; for when it has become necessary to operate for varicose ulcer of the leg so large a number of the veins are involved (both superficial and deep) that an operation for complete obliteration is impossible, and something no prudent surgeon would attempt.

Mr. Erichson, with his extensive experience, after having operated over one hundred and fifty times for obliteration, says, "But can the disease be cured by the local obliteration of the vein? To this question I have no hesitation in answering in the negative. Though the trunk be obliterated, a collateral venous circulation is set up which is very apt in the course of a few months to take on a varicosed condition, and thus to cause a return of the disease some time after the operation." Indeed, it is conceded by eminent surgeons that this is not only true in the case of varicocity of the extremities, but also that when the disease is found in other parts of the body, operative procedure can be considered only as palliative in most cases. Now, if in the operation for obliteration the cure is not radical, but the return of the ulcer may be expected some time after the operation, and the patient must in the end resort to the elastic bandage or stocking; and if by the permanent use of the elastic

bandage we can relieve all the conditions better than we can expect from the most favorable operation, and that, too, without the artificial excitation of phlebitis, in which case the inflammation may pass beyond the adhesive stage into that of suppuration, or diffuse inflammation, thereby endangering the life of the patient, would it not be better in all cases to discard the radical operations? (and by this term I wish to include not only the operations of incision and ligation, but all the operations that have ever been practiced, for they all have a common design, namely, the obliteration of the veins, and are all liable to produce diffuse phlebitis, no matter whether we use the metallic clamps, cauterization, or injection.)

But it is sometimes argued that patients object to the continued use of the elastic bandage on account of expense and inconvenience, but in my experience this has not been the case. After the ulcers are healed my patients always wear either the elastic stocking or bandage, which feels quite comfortable even in warm weather; and as for expense, the best silk stocking, extending as far as the knee, which is used more than any other length), can now be purchased for $2.00 and the elastic webbing at 40 cents per yard, which places these articles within. the reach of the poorest patients; besides, it is usually necessary to use one or the other of these appliances in any of the radical operations to protect for a while the recently accluded veins that they may not immediately reopen.

I have been accustomed in most cases where the surface of the ulcer is smooth and glassy,-of a pale color with the edges raised and thin,-to apply a fly blister followed by same stimulating lotion; that this is sometimes a valuable adjuvant to the bandage by stimulating healthy granulations and causing a more rapid healing of the ulcer, I am willing to admit; but blistering is an application hard to bear, and in one case I had a good deal of trouble from strangury; and as I am confident the elastic bandage will cure any case of varicose ulcer without the aid of any other auxiliary, I believe in the future I shall abandon blistering in most cases entirely.

Esmarch's elastic webbing is far superior to any other bandage in these cases. The ordinary roller bandage becomes loose as soon as the edematous condition of the parts begins to subside and consequently affords little support to the tissues until it is reapplied, besides it is liable to slip from its position. The pure rubber bandage is impervious to moisture and prevents evaporation, while the elastic webbing always retains its position, is not impervious to moisture, does not prevent the

free evaporation of the natural moisture of the part, and by its elasticity it keeps up continued pressure on the tissues.

I believe that rarely if ever a case of varicose ulcer exists that cannot be cured by the persevering use of the elastic bandage, and in consulting text books upon this subject I have always found in my judgment a tendency among authors to place too little stress upon this part of the treatment and to advocate too strongly the operative procedure. I have therefore endeavored in this short paper to bring this fact more prominently before the profession. If I have succeeded my object is accomplished, and time of the Society has not been spent in vain.