ON THERAPEUTICS AND ON THE NATURAL HISTORY OF DISEASE

E.J. Tilt
1868 The Lancet  
461 those other changes of the skin, bronzing, induration, and < ulcer, were in much more constant correspondence than with i varicosity. 1 Now, in 2 cases external varicosity existed alone : none of I the sub-aponeurotic structures were in anywise diseased or I disturbed. In the other 7, with external varicosity there were other complications, but no other disease of the skin. These complications were as follows :-In 1 there were beaded strings of coagulum in the varicose veins; in 2 there was
more » ... ins; in 2 there was dilatation of the intra-muscular veins; in 3 the deep trunk veins were diiated ; in 5 there were coagula in the deep trunk veins, in 2 instances obstructtve; whilst in 2 others the arteries were slightly diseased. But this statement does not represent the condition of the parts logically. It only shows that, with superficial varicosity, there are other serious lesions ofecting both arteries and veins, deep and supelfcial, which canuot be ignored in discussing the relation to it of associated diseases. Now the several conditions of the various vessels in these cases were differently combined; and it is to these especial and individual groupings that the greatest amount of importance must be attached. Although coagula were found in the trunk veins in 5 out of the 9 cases, these were, as I have said, obstructive in 2 only; and of these cases in 1 only did the obstruction affect the deep trunk veins, the obstructed vein being in the other case but an intra muscular branch. In 1 only was there thrombose obstruction of the deep venous trunks with superficial; . varicosity; and, be it further noticed, in this, as in the other thrombose case, as well as in 1 beside, in which an old clot in the deep veins had ceased to be obstructive, there was co-ordinate dila-' tation of other of the trunk comitial veins. It appears, then, that in no one of these cases in which varicosity existed alone, was there coincident obstruction of deep trunk veins, although there were those especial signs of derangement of these vessels and their contents in most instances, and of the arteries as well in 2, as would lead to the conclusion that the general circulation had been subject to very considerable and long-standing embarrassment. ' In relation to ulcer the bearing of these remarks is this : that varicosity may exist with mere embarrassment of the whole vascular .M/6)K. of the limb, and yet u-ithout ulceration. I shall now go a step further, and give a summary of the condition of the vessels of the leg in 10 cases, of which varicosity was associated with bronzing and induration of the skin in 1 case, and with ulcer and discoloration in the other 9. The, former I shall not further consider. It arose from capillary congestion, and was associated with obstructive cardiac disease and great dilatation of the deep venous trunks. In 3 of these coagula were found in the trunk of the external ' 8f1tpkenpus vein. (I may here explain that, from a large number, of dissections, I have come to the conviction that the anatomy of that vessel, as given in works, is, in one most important point, incorrect. We have all, I think, been taught that this vein takes its course obliquely along the outside and back of the leg to the popliteal space, where it penetrates the fascia to reach the popliteal vein. In a large number of dissections that I have made for the purpose of clearing up this point, I have not found this course taken by the vein in a single instance. It invariably pierces the deep aponeurosis below the calf of the leg, immediately behind the junction of the gas-z , trocnemius, and completes its course below the aponeurosis, and sometimes even within one of the bellies of the muscle itself. It was in portions of the external saphena adjoining this foramen that these clots were found.) In 6 there was obstruction of the deep trunk veins by coagula. In 3 there was dilatation of the deep trunk veins. And in 6 there was arterial disease, more or less severe. I must again collate these cases, so as to present the distinct groupings of the several morbid phenomena. In 1 case the external saphenous vein was obstructed, with disease of the anterior and posterior tibial arteries. In 2 other instances, in which the external saphenous veins were obstructed, there was also obstruction of the deep trunk veins ; with, in 1 of these, dilatation of deep trunks, and arterial incompetency. In 3 others there was deep trunk obstruction, with like arterial incompetency; with, in 1 of these also, dilatation of deep trunk veins. (It will be understood that in speaking of dilatation and obstruction of deep trunk veins in the same leg I am speaking of different conditions of two comitial veins.) In one case, already referred to, in which a very large proportion of the integument of the leg had been eaten away by deep ulceration, all of the main arteries were found coated with earthy matter, and had become, as it were, functionally obsolete. In this case, which Mr. Hopgood injecte(i ith wax for me, I was interested to observe the unusual vascularity of & p o u n d ; the remaining tissues as far as the arterial system was con cerned. The diseased vessels sent off an unusual number of healthy branches, which supplied the tissues which the ulcer had spared, and these anastamosed freely with each other in the course of their ramifications. Now the general conclusion from the second series of dissections is that, unlike the jormer, venous obstruction, especially of trunk veins, superficial and deep, was, in severe cases, found to be associated as well with arterial incompetency. Contrasting this with the conclusion arrived at from the details of the first series, and remembering that there was no ulcer in the former, but ulceration with bronzing and induration in all the latter cases but one, and that an unimportant one, it is impossible, I think, to avoid the further inference that ulceration is not a direct consequence of varicosity, but of other conditions of the venous system, with which varicosity is not urlfreqvently a complication, but without which neither one of these affections o,' the skin is met with-conditions which involve obstruction of the trunk veins, deep and superficial, either from impediments on the venous side or incompetency on the arterial, or from both causes combined. I think then that, pathologically, the doctrine of the " varicose ulcer" does not hold water; that, to reiterate my conclusions, ulceration, when it exists with varicosity, but without other complication, is a coincidence, and not a consequence of the vein disease ; that, when associated with induration and bronzing of the skin, it is the direct result of serious obstruction of the venous trunks, and this alone, whether associated with varicosity or not. The converse cannot, however, be alleged-namely, that serious embarrassment to the circulation through the trunk veins is invariably followed by these affeotions of the skin. The anomaly, which does not admit of explanation here, does not invalidate the foregoing conclusions. (To be concluded.) ________________ ON CONSULTING PHYSICIAN TO THE FARRINGDON DISPENSARY, ETC. AN eclipse of faith is spreading over the face of English medicine, and there. is a tendency to-disparage the large amount of therapeutical knowledge that has been accumulated ; but those who regret this tendency will remember that medicine its not bounded by our line of coast. If some of our most eminent men have no longer faith in medicines, there is no want of that faith on the continent. With regard to France I have watched the variations of medical belief, during the last thirty years, and it will be useful to compare these changes with those progressing in England during the same period. Broussais pub. lished in 1816 the first edition of his "Examen des Doctrines Medioales," and by four editions of this work, and by his numerous contributions to the medical press, all burning with passionate eloquence, the doctrine of inflammation, as the cause of all diseases, spread like wildfire ; but it almost died out as fast, for although the last edition of his work was published in 1829, when I began the study of medicine in 1834 gastrite was already the standing joke of medical students, and as Broussais had been most virulent in his attacks upon the polypharmacie of former ages, when the profession lost faith in bleeding and leeches, they had only expectation to fall back upon.
doi:10.1016/s0140-6736(02)61650-2 fatcat:rjgedezh5neble4f7ypnegbmqi