[On the ancient and magical lesions in the sixteenth to eighteenth centuries]. / Über die alten und zauberischen Geschwäre im 16. bis 18. Jahrhundert.

At the beginning of the Renaissance magical, witchcraft and demonological medicine still played a large role in the poor healing ability of chronic leg ulcers. This included the general administration of magical potions and topical application. An example of the manipulation of the whole body by the devil was the Abracadabra text from Johann Christoph Bitterkraut in the year 1677. The use of bewitched ointments was particularly propagated by Paracelsus in 1622; however, even as early as the beginning of the seventeenth century, the invocation of supernatural powers was slowly diminishing until at the beginning of the nineteenth century the medical schools on chronic leg ulcers could be cultivated at the universities and by specialized wound healers.

[Puerperal sepsis in the 19th century and Trendlenburg's ligature of the internal iliacal vein]. / Puerperalsepsis im 19. Jahrhundert und Trendelenburg-Ligatur der V. hypogastrica.

With the establishment of institutions for child delivery in city hospitals and with incorporation of routine autopsy into the field of activity of assistants at birth, childbed fever spread epidemically and was fatal in most cases. Nearly every third woman in childbed died of puerperal sepsis in the Hôtel Dieu in Paris and in the Erste Wiener Gebärklinik in Vienna. The tragic fate of obstetrician Ignaz Semmelweis began here, he recognized disease transmission from pus and body parts by physicians during the process of delivery. At the end of the 19(th) century puerperal sepsis occurred less frequently, its course was nevertheless equally dramatic. Pathophysiologically a septic thrombophlebitis of the ovarian vein was seen as the primary cause of the pyaemia. Yet, the ligature of the vessel did not alter the deadly course of the disease. Based on sections Trendlenburg realized that the internal iliacal vein plays a much greater role in protracted pyaemia. Thereupon he performed a ligature of this vessel. The long course of a complicated infection took a good turn with this operation. Trendlenburg's ligature and resection of the ovarian and internal iliacal vein were usually combined with hysterectomy. In the following decades this great operation of seriously ill women in childbed found agreement as well as rejection. Most interventions did not save the lives of the patients. Before antibiotic therapy was introduced, physicians were almost helpless against puerperal pyaemia.

Invasive therapeutic options in truncal varicosity of the great saphenous vein.

It is known from current pathophysiology that disease stages I and II of truncal varicosity of the great saphenous vein do not cause changes in venous pressure on dynamic phlebodynamometry. This is possibly also the case for mild cases of the disease in stage III. In pronounced cases of stage III and all cases of stage IV, however, venous hypertension occurs which triggers the symptoms of secondary deep venous insufficiency and all the complications of chronic venous insufficiency. From these facts the therapeutic consequence is inferred that in stages I and II and perhaps also in very mild cases of stage III disease, it is enough "merely" to remove varicose veins without expecting there to be any other serious complications in the patient's further life caused by the varicosity. Recurrence rates are not included in this analysis. In marked cases of disease stages III and IV of the great saphenous vein, however, secondary deep venous insufficiency is to be expected sooner or later. The classical operation with saphenofemoral high ligation ("crossectomy") and stripping strictly adheres to the recognized pathophysiologic principles. It also takes into account in the greatest detail aspects of minimally invasive surgery and esthetics. In the past few years, developments have been advanced to further minimize surgical trauma and to replace the stripping maneuver using occlusion of the trunk vein which is left in place. Obliteration of the vessel is subsequently performed via transmission of energy through an inserted catheter. This includes the techniques of radiofrequency ablation and endovenous laser treatment. High ligation is not performed as a matter of principle. In a similar way, sclerotherapy using microfoam is minimally invasive in character. All these procedures may be indicated for disease stages I and II, and with reservations also in mild forms of stage III disease. Perhaps high ligation previously constituted overtreatment in some cases. Targeted studies are still needed to prove whether secondary deep venous insufficiency can be avoided in advanced stages of varicose vein disease without high ligation and thus without exclusion of the whole recirculation circuit.

[Armand Trousseau, phlegmasia alba and gastric cancer]. / Armand Trousseau, die Phlegmasia alba und das Magenkarzinom.

Armand Trousseau (1801-1867) was one of the greatest doctors of our cultural heritage. He regarded medicine as an art form expressed through the individuality of the physician. While still a young man, he was appointed professor of therapeutics and pharmacology at the University of Paris. He was a master of rhetoric and lectured on general medicine and neurology at the bedside. Trousseau recognised that phlegmasia alba was frequently associated with malignant disease. His description of the causality in his most famous work Clinique médicale de l'Hôtel Dieu de Paris is impressive. When he later suffered phlebitis of the left arm, he correctly diagnosed stomach cancer, from which he died six months later.

[Painless phlebography (author's transl)]. / Die "schmerzlose Phlebographie"

The routine employment and wide indications for ascending phlebography for evaluating the deep and superficial systems prior to specific therapy makes it desirable that the patient should feel as little pain as possible. By using suitable measures before and after the examination, optimal position of the patient and appropriate choice of instruments, as well as local anaesthesia with a Dermo-Jet pressure injector, it is possible to render the examination almost completely painless.

[Diagnosis of secondary popliteal and femoral venous insufficiency in truncal varicose veins]. / Diagnostik der sekundären Popliteal- und Femoralveneninsuffizienz bei Stammvarikose.

Serious truncular varicosis causes, after a long period of time, changes in the deep veins known as secondary popliteal- and femoral vein incompetence. The ascending pressphlebography is the common diagnostic method. The continuous-wave sonography showing a sensitivity of 3% while being 100% specific is therefore not a suitable diagnostic method. The duplex-sonography proves to be the optimal screening method with a sensitivity of 100% while being 87% specific.

[Vascular manifestation of von Recklinghausen neurofibromatosis: case report of venous dysplasia]. / Vaskuläre Manifestation bei Neurofibromatose von Recklinghausen: Kasuistik einer venösen Dysmorphie.

We present the case report of a patient with neurofibromatosis and regional dysmorphism in the superficial femoral vein. Colour coded duplex sonography revealed an incidental finding: thickening of a short portion of the vein wall with calcification. This unusual finding strongly suggests a causal relationship. Pathological processes in the arteries have often been described in patients with von Recklinghausen's disease (neurofibromatosis). Dysplastic and hyperplastic reactions of the intramural nerve tissues and the smooth muscle elements in the vascular wall have been observed. This leads to the formation of aneurysms and arteriovenous fistulas and to stenosing processes in the peripheral, visceral and cerebral arteries. However, involvement of the veins in type 1 von Recklinghausen's neurofibromatosis has only been reported in old histopathological studies of medium-sized and small vessels.

Acetylsalicylic acid--reocclusion--prophylaxis after angioplasty (ARPA-study). A randomized double-blind trial of two different dosages of ASA in patients with peripheral occlusive arterial disease.

We report on a randomized controlled clinical trial in patients with peripheral occlusive arterial disease who have been successfully treated with angioplasty. The efficacy and the rate of side effects of two doses of ASA (300 mg vs. 1000 mg daily) have been compared during a treatment period of 6 months after angioplasty. It was planned to include a total of 600 patients in the trial. A predefined interim analysis of 200 patients which was performed after the actual inclusion of 218 patients showed identical reocclusions rates and a very similar frequency of side effects in both treatment groups. The study was then terminated since it was not expected that further continuation would lead to a relevant difference between the two treatment groups concerning efficacy or side effects. Patients already included in the trial at the interim evaluation were included in the final analysis, leading to a total number of 223 patients. Finally 112 patients had been randomized to receive a daily dose of 300 mg ASA and 111 patients to receive 1000 mg ASA. Reocclusions occurred in 18 patients (16%) on 300 mg of ASA/day and in 20 patients (18%) receiving 1000 mg ASA/day. The study was interrupted because of side effects in 27 patients (24%) in the 300 mg/day group and in 27 patients (24%) in the 1000 mg/day group. Mostly subjective gastric complaints were the cause of interruption in 17 patients (15%) in the 300 mg group and in 21 patients (19%) receiving the higher dose regimen. So the reocclusion rate was identical in both dosage-groups.(ABSTRACT TRUNCATED AT 250 WORDS)

The chronic venous compartment syndrome.

BACKGROUND: A chronic exertional compartment syndrome has only been observed in athletes and soldiers. In the vast majority, the disease affects the anterior compartment and the fibular muscle group, and only rarely the lateral and dorsal muscle compartments. Muscle tissue necrosis does not occur. In the course of venous diseases with a severe chronic venous stasis syndrome, a chronic venous compartment syndrome develops that differs considerably from the familiar functional syndrome. The predominant symptom is an uncurable cuff ulceration on the lower leg. PATIENTS AND METHODS: From 1993 to 1996 a total of 16 patients with a chronic fascial compression syndrome underwent surgery on 18 extremities. The crural fascia was resected and a mesh graft was applied. RESULTS: In the group of ten controls with healthy veins the average pressure in the deep compartment was 13.6 mmHg (range 9-17 mmHg) lying down and 29.9 mmHg (range 15-42 mmHg) standing up. In 14 patients with chronic fascial compression syndrome, the average pressure was higher, measuring 21.1 mmHg (range 8-47 mmHg) lying down and 62.5 mmHg (range 33-87) standing up. After surgery, the pressure dropped to 15.5 mmHg (range 5-24 mmHg) lying down and 34.5 mmHg (range 10-58 mmHg) standing up, but did not fall as low as the average values recorded in the control group or in the patient's healthy leg. The results from the standing up position were statistically significant (p = 0.003). Computed tomography showed major changes in the muscles indicating muscle atrophy and fatty degeneration. The crural fascia seemed to be incorporated in the scars of the subcutaneous tissue in large areas. After crural fasciectomy and healing of the ulceration, the tissue structure of the muscles recovered. CONCLUSIONS: In chronic fascial compression syndrome, the trellis arrangement of the collagen fibres becomes disordered. This results in a loss of flexibility during muscle contraction. Every step causes an increase of intracompartmental pressure and microstructural injury. The consequence is resection of the crural fascia.

[Development of large vein surgery in Europe]. / Die Entwicklung der grossen Venenchirurgie in Europa.

Surgery of the great veins inevitably began with the surgical treatment of injuries, often involving the femoral vein. Because of the famous case presented by Roux in 1813, the prevailing opinion until almost the end of the nineteenth century was that ligation of the vein made death inevitable, but that the only way to control severe hemorrhaging from a vein was to ligate the femoral artery. Zaufal's principle (1880) consisted in the ligation and resection of great veins of the body and limbs in order to prevent sepsis in suppurative processes. This surgical method was still being used in the first half of the twentieth century in patients with perforated appendicitis or puerperal fever. In the limb, the congestion induced in the vein had a positive effect on the healing process. The surgical treatment of leg and pelvic deep vein thrombosis was initially (1931) aimed at achieving decompression in compartment syndromes. The first thrombectomy was performed in 1937, but several operations with a successful outcome were reported at the 61st annual meeting of the German Society of Surgery in the following year.