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Emblem of Hunczovksy*
xi
Venous Ulcers
Copyright © 2007 by Academic Press, Inc.
All rights of reproduction in any form reserved.
This graphic symbol with its caption, “In Union Health,” depicts the
age-old emblems of medicine: the Aesculapian rod with a serpent and
another rod showing a hand with an eye in its palm. Bringing these two
emblems together in this way represents a unifi cation of the disciplines of
medicine and surgery to form a combined medical practice. In 1787 such
a unifi cation was hoped to be successful in improving total patient care
and offering an advantage to all who were sick.
The occasion for the development of this symbol was the second anni-
versary of the opening of the 2000-bed Vienna General Hospital and its
merger with the 1200-bed Academia Medico-Chirurgica “Josephina.”
These two institutions were combined to provide the best possible care
with the best equipment available. The new institution was founded by
Emperor Joseph II, who had traveled throughout Europe and learned of
the improvements in education of military surgeons in France and the
elevation of surgeons to academic rank by King Louis XV.
The great Vienna General Hospital eventually became the site of a
massive collection of precious medical books, surgical equipment, and the
historical anatomic wax museum. It was also the location of the military
medical school known as the Josephinum. In the twentieth century the
symbol of the Vienna General Hospital became the signet of the Austrian
Society of Surgeons as a reminder of the original attempt to create modern
surgery approximately 200 years earlier.
*Modifi ed from Holubar K. In unione salus: A short historical perspective on the devel-
opment of surgical education in Austria in the 18
th
century. Va sa 1991; 20:10–11.
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In its original form, the emblem was chosen by the Working Group
for Phlebology of the Austrian Society of Dermatology. This choice was
appropriate because the rod of Aesculapius represents academic theoreti-
cal traditions of medicine and conservative nonsurgical care. The seeing
hand, which “sees” what the hand does, is the symbol for both experience
in medicine and the manual dexterity associated with surgical skill.
To physicians dedicated to the care of the patients with varicose veins
and telangiectasias, the symbol is a reminder of the union of surgery
and sclerotherapy, and alliance that is necessary for optimum care of the
venous insuffi ciency produced by microphlebectasias and macrophlebecta-
sias. Chosen to be the logo for the Fifth European-American Venous
Symposium in Vienna, this symbol is an appropriate cover for this book.
xii Emblem of Hunczovksy
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Contributors
Said Abisi, Department of Academic Surgery, St. Thomas Hospital, SE1
7EH London, UK
Jamie R. Barwell, Department of Vascular Surgery, Cheltenham General
Hospital, GL53 7AN Gloucestershire, UK
John J. Bergan, Vein Institute of La Jolla, La Jolla, CA 92037
Dale Buchbinder, Vascular Surgery, The Greater Baltimore Medical
Center, Towson, MD. 21204
Sharon B. Buchbinder, Department of Health Sciences, Towson Univer-
sity, Towson, MD 21204
Warner P. Bundens, Departments of Surgery, Family and Preventative
Medicine, University of California-San Diego, La Jolla, CA 92037-0974
Kevin Burnand, Department of Academic Surgery, St. Thomas Hospital,
SE1 7EH London, UK
Juan Cabrera, Phlebology Unit, University Clinic of Navarra, 31008 Pam-
plona, Spain
Joseph A. Caprini, Northwestern University Feinberg School of Medicine,
Evanston Northwestern Healthcare, Skokie, IL 60077
Van L. Cheng, Vein Institute of La Jolla, La Jolla, CA 92037
Alessandro Frullini, Studio Flebologico, Incisa Valdarno, Florence, Italy
Manjit S. Gohel, Department of Vascular Surgery, Cheltenham General
Hospital, GL53 7AN Gloucestershire, UK
xiii
Venous Ulcers
Copyright © 2007 by Academic Press, Inc.
All rights of reproduction in any form reserved.
https://t.me/med1917
Colleen M. Johnson, Southern Illinois University School of Medicine,
Springfi eld, IL 62794
Stephen J. Kovach, Division of Plastic, Reconstructive, and Maxillofacial
Surgery, Duke University Medical Center, Durham, NC 27710
Nicos Labropoulos, Division of Vascular Surgery, University of Medicine
and Dentistry of New Jersey, Newark, NJ 07103
Jeffrey H. Lawson, Department of Pathology, Duke University Medical
Center, Durham, NC 27710
L. Scott Levin, Division of Plastic, Reconstructive, and Maxillofacial
Surgery, Duke University Medical Center, Durham, NC 27710
Brian Lewis, Medical College of Wisconsin, Milwaukee, WI 53226
William A. Marston, Division of Vascular Surgery, University of North
Carolina at Chapel Hill, Chapel Hill, NC 27599
Lisa Mekenas, Vein Institute of La Jolla, La Jolla, CA 92037
Robert B. McLafferty, Southern Illinois University School of Medicine,
Springfi eld, IL 62794
Olle Nelzén, Skaraborg Leg Ulcer Center and Vascular Surgery Unit,
Skaraborg Hospital/KSS, 541 85 Skövde, Sweden
Martino HA Neumann, Department of Dermatology, Erasmus Medical
Centre Rotterdam, Rotterdam, The Netherlands
Francisco J. Osse, Department of Surgery, University of Iowa Health Care,
Iowa City, IA 52242
Hugo Partsch, Medical University of Vienna, A-1160 Vienna, Austria
Luigi Pascarella, The Whitaker Institute of Biomedical Engineering, Uni-
versity of California-San Diego, La Jolla, CA 92093-0412
Michel R. Perrin, Clinique du Grand Large, F-69680 Chassieu, France
Keith R. Poskitt, Department of Vascular Surgery, Cheltenham General
Hospital, GL53 7AN Gloucestershire, UK
Pedro Redondo, Department of Dermatology, University Clinic of
Navarra, 31008 Pamplona, Spain
Geert W. Schmid-Schönbein, The Whitaker Institute of Biomedical Engi-
neering, University of California-San Diego, La Jolla, CA 92093-0412
Cynthia K. Shortell, Department of Surgery, Duke University Medical
Center, Durham, NC 27710
xiv Contributors
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Michael J. Stirling, Duke University Medical Center, Durham, NC 27710
Patricia Thorpe, Endovenous Reconstruction, Arizona Heart Hospital,
Phoenix, AZ 85016
Jonathan B. Towne, Medical College of Wisconsin, Milwaukee, WI
53226
Jose L. Trani, Jr., Department of Pathology, Duke University Medical
Center, Durham, NC 27710
Stylianos K. Tsintzilonis, University of Medicine and Dentistry of New
Jersey, Newark, NJ 07103
Tryfon Vainas, Department of Surgery, Maastricht University Hospital,
Cardiovascular Research Institute of Maastricht, 6202 AZ Maastricht, The
Netherlands
Jeroen DD Vuerstaek, Department of Dermatology and Phlebology, Der-
maClinic, 3600 Genk, Belgium
Mark R. Whyman, Department of Vascular Surgery, Cheltenham General
Hospital, GL53 7AN Gloucestershire, UK
Contributors xv
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Foreword
xvii
Venous Ulcers
Copyright © 2007 by Academic Press, Inc.
All rights of reproduction in any form reserved.
Development of endovascular surgery during the past 25 years has been
at a fast and furious pace. It is a tribute to those who have worked in this
exciting fi eld that the new techniques have been so well accepted and uni-
versally employed.
In contrast, until recent years, the venous system has been relatively
neglected clinically. Dogma, rooted in the pronouncements of infl uential
surgeons of 100 years ago, still permeates clinical decision making.
However, developments in understanding the pathophysiology of the
venous system have kept pace with the developments in endovascular
surgery. This has been due to the universal acceptance of ultrasound as a
clinical imaging tool as well as its utility in documenting pathologic
anatomy.
This book, utilizing the new information uncovered by ultrasound, takes
a long step forward in the right direction to bring new developments in
diagnosis and treatment of venous leg ulcers into one volume. Here, in one
place, an outstanding group of contributors has set down their best current
concepts. Nearly all of the acknowledged experts in the fi eld of venous
investigations have made their contributions.
Even a cursory look at the table of contents shows the names of many
who have made basic observations and also those who have vast clinical
knowledge and experience in treating venous leg ulcers. Innovations in
patient care are included. The coverage is comprehensive, succinct, and
complete. Attention has been given to the several disorders that lead to
venous leg ulcers, and the problems of patient care are covered thoroughly.
The latest diagnostic tests and indications for their use are well
described.
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So often, medical textbooks suffer from the presentation of familiar
fi ndings and repetition of data that are universally available. It is to the
credit of the contributors of the chapters in this book that their texts
present current concepts and new data to challenge the reader. Contribu-
tions from international authors from many countries enhance the value
of this volume as a source of reference material. This is a timely publication
that should be of interest to many individuals, as well as those who have a
specifi c interest in venous disorders.
Mark Talamini, MD
Professor and Chairman
Department of Surgery
UCSD Medical School, San Diego
xviii Foreword
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Preface
Venous ulceration is the most common and serious consequence of
severe chronic venous insuffi ciency. Unfortunately, even today it is one of
the most poorly managed medical conditions. Interestingly, the manage-
ment of venous ulcers has not progressed very far beyond that advocated
by John Hunter over 200 years ago. Hunter said, “the sores of poor peo-
ple . . . are often mended by rest, a horizontal position, fresh provisions,
and warmth.”
Also, 100 years ago, John Gay, a London surgeon, described the rela-
tionship of venous ulceration to ankle perforating veins. The concept was
supported by Homans at Harvard, Turner Warwick at the Middlesex Hos-
pital in London, Robert Linton at the Massachusetts General Hospital,
and, of course, Frank Cockett at St. Thomas’ Hospital who generously lent
his name to the three main ankle perforators. These four names remain
famous in history of the treatment of venous ulcers, and each surgeon had
his own concept of care. Linton’s, for example was subfascial exploration;
Cockett’s was suprafascial.
In countries other than the United States, a heavy workload is imposed
on nurses in dressing ulcers. What is less appreciated or well known is the
long-term ineffectiveness of such ulcer treatment. Negus found in his clinic
that 77 patients with 109 ulcerated legs had continuous or intermittent
ulceration for prolonged periods of time ranging from a few months to
more than 50 years. In Negus’s clinic in the center of a well-doctored area,
all of his patients were treated by conventional methods before arriving at
his clinic.
Since the last century a great deal has been learned about the pathogen-
esis and, therefore, the treatment of venous ulceration, but it still remains
xix
Venous Ulcers
Copyright © 2007 by Academic Press, Inc.
All rights of reproduction in any form reserved.
https://t.me/med1917
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