A Hydrostatic Pressure Stocking for the Treatmentof Ulcers due to Chronic Venous Insufficiency

By J. EDWIN WOOD, M.D.

Chronic venous insufficiency may be complicated by ulceration of the skin of the involvedextremity. The ulcers appear to be caused by the prolonged elevation of venous pressure

in the leg and the resultant edema. A device is described that counterbalances exactlythe elevated pressure in the veins of the leg, regardless of the position of the patient.This hydrostatic pressure stocking prevents formation of edema without interferingwith the flow of blood through the tissues. The use of this device in the treatment ofulcers due to chronic venous insufficiency is also described.

CHRONIC venous insufficiency' is a rela-tively common2 syndrome that is caused

by sustained elevation of the pressure in theveins of the dependent lower extremity. Thishigh mean venous pressure results from in-adequate closure of the valves in the veinsduring exercise of the muscles of the leg,especially if some of the venous channelsare obstructed due to previous thrombophlebi-tis.3-7 The high venous pressure is associatedwith an abnormally high capillary pressure,which is responsible in turn for the formationof edema in the tissues of the extremity.The skin overlying these edematous areas

may break down either following a minorinjury or without apparent cause. Subse-quently these small breaks in the skin tendto become large superficial ulcers. The ques-tion then arises as to whether the edema perse causes these ulcers by direct mechanicaldestruction of tissue or by separation of liv-ing cells from their immediate blood sup-ply.8' 9 Alternatively, the primary cause ofthe ulceration may be infarction of the skindue to diminished flow of blood. A decreasein the flow of blood would presumably occurin the absence of proper functioning of thevenous valves, which allow a contractingskeletal muscle to propel blood out of theFrom the Department of Medicine, Boston Uni-

versity and Massachusetts Memorial Hospitals, Bos-ton, Mass.; and from the Department of Medicine,Georgia Heart Association Laboratory for Cardio-vascular Research, Medical College of Georgia,Augusta, Ga.

Presented in part to the New England Cardiovascu-lar Society, Boston, Mass., January 14. 1957.

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veins of the leg.8 A further momentary re-duction of blood flow and an increase intissue pressure as well might occur with thesudden rise of venous pressure caused bycoughing or the Valsalva maneuver.9

Ulcers due to venous insufficiency willeventually heal with prolonged continuousbed rest and elevation of the involved ex-tremity. The essential effect of this therapyappears to be one of marked lowering ofvenous pressure in the legs and consequentdissipation of the edema. Such results sug-gest that a patient might avoid hospitaliza-tion if it were possible to prevent the forma-tion of edema by maintaining very low localtransmural venous and capillary pressuresby adequate but not excessive external com-pression of the extremity. Excessive externalcompression would reduce transmural arterialpressure without a further reduction of trans-mural venous pressure,'0 thus diminishingthe arterial-to-venous pressure gradient andreducing the volume of blood flowing throughthe tissues. Therefore, the pressure to becounterbalanced within the veins of the legwould be equal to that of a vertical columnof blood (or for practical purposes, water)between any given point on the leg and thelevel of the right atrium, regardless of theposition of the patient." It is the purposeof this communication to describe a devicethat has been designed to produce counter-pressure upon the extremity in just thismanner. The use of this device in the treat-ment of ulcers due to chronic venous insuffi-ciency is also described.

Circulation, Volume XX, Peceember 1959

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1WOOD

FIG. 1. Lateral view of patient wearing hydrostaticpressure stocking.

METHODSThe primary component of the device& for comi-

pressing the leg was a knee-length, toeless stock-ing made of Nylon-cotton cloth. This stockingcould be opened anteriorly with a zipper. It wasfitted with laces along the lateral side to allow ad-justment of its size. The size could also be ad-justed across the dorsum of the foot. A watertightbladder was incorporated into the medial surfaceof the stocking. This bladder extended from theknee to a point just below the medial malleolus,and from the midline anteriorly to the midlineposteriorly of the leg. A second smaller bladderwas attached to the bladder in the stocking with 2flexible rubber tubes 3 feet in length. There wasan opening in the smaller bladder which was usedto fill the entire system with 750 ml. of water.After the air was removed from the system thisopening was closed. There were no valves in thesystem and the water could flow through the tubesfrom one bladder to the other. A strap was at-

*Manufactured by the David Clark Company,Worcester, Mass.

tached to the smaller bladder so that it could besuspended beneath the axilla (fig. I).

Pressures were measured beneath the hydrostaticpressure stocking from a 3-by-1.5 en., flat, water-filled, plastic capsule that had beeni placed betweenthe skin and the stocking. This capsule was at-tached to a rigid plastic tube leading to a StathamnP23D strain gage. Records were obtained with aSanborn direct-writing oscillograph. Pressureswere measured with the subject in the recumbent,sitting, and standing positions. Twelve points wereused for these measurements in 3 subjects. Thesepoints were at the top, middle, and lower aspectsof the leg anteriorly, posteriorly, laterally, andmedially. The data are reported in terms of thedifference between the observed and the predictedpressures. Pressures were predicted on the basisof the vertical distance between the capsule andthe level of the center of the bladder in the axilla.The hydrostatic pressure stocking was used as

a sole means of therapy for 10 ambulatory pa-tients with leg ulcers due to chronic venous in-sufficiency. The ulcer was covered with a steriledressing held in place with gauze and adhesivetape. A knee-length elastic stocking was wornover this dressing, then the hydrostatic pressurestocking was placed on the leg and the smallerbladder was strapped beneath the axilla. The pa-tient was instructed to wear the hydrostatic pres-sure stocking from the time that he got up in themorning until he retired at night. Some of thefemale patients wore an opaque cotton stockingover the hydrostatic pressure stocking while otherspreferred to wear slacks. Male patients wore anordinary sock over the hydrostatic pressure stock-ing. Since the tubes that connected the 2 bladderswere small and flexible, the patient could conven-iently wear the entire device beneath his clothing.Special shoes were not required. The dressingswere changed only as often as was necessitated byexudation from the ulcer surface.

RESULTSTen patients with chronic venous insuffi-

ciency associated with large ulcers of theskin of the leg were treated with the hydro-static pressure stocking. All of the patientswere urged to follow their usual dailyroutines.

Healing of the ulcers occurred in all ofthe patients. The rapidity with which thehealing took place seemed to depend prima-rily upon the original size of the ulcer. Thehydrostatic pressure stocking did not appearto shorten or lengthen the period of time

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HYDROSTATIC PRESSURE STOCKING1

required for healing of the ulcers comparedwith the period of time which might havebeenl required for healing had the patientbeen hospitalized. Seven of the patients hadhad thrombophlebitis while the remaining 3were apparently suffering from ulcers dueexclusively to varicose veiiis. Initially, theulcers were 3 to 8 cm. in diameter. The timerequired for complete epithelialization of theulcer surfaces varied from 2 to 5 weeks. Fourof the patients had experienced considerablepain in the region of the ulcer during de-pendeuicy of their legs. The hydrostatic pres-sure stocking relieved this pain completely.In all cases, the gross edema was dissipatedwithin 3 to a davs after initiation of thetherapy. The patients found the stocking tobe more bulky and noticeable than an ordi-nary elastic stocking. They grew used to itafter several days, however, and said that itdid not interfere with their activities in anyway.The device was worn by a school instructor

virtually continuously for a period of 2 yearswithout interruption of his teaching duties.His difficulties were initiated by severethrombophlebitis in the deep and superficialveins of the leg. After this, but prior to useof the hydrostatic pressure stocking, he hadbeen hospitalized at yearly intervals for 6-to 8-week periods over a span of 6 years,because of repeated and extensive ulcer for-mation. All of the indicated surgical proce-dures to the venous system of his legs hadbeen performed 3 or more years prior toinitial use of the hydrostatic pressure stock-ing. During the subsequent 2 years when hewore the stocking it was not necessary tohospitalize him. Two ulcers on one leghealed completely with this form of therapy.Following this it was necessary for him tobe without the device on 2 occasions for 3-week periods and in each instance an ulcerappeared but healed again upon resumptionof therapy.A second patient continued to work as a

cook in a restaurant while wearing the hydro-static pressure stocking. His job required

that he stand for most of the day. An ulcer3.5 cm. ill diameter, due apparently to vari-cose veinls, healed during 4 weeks of treat-merit with the stocking. Then he stoppedwearing the stocking and elected to defersurgical therapy of his varicose veins. Whena second ulcer 0.5 cm. in diameter occurred11 months later, he was hospitalized for liga-tionI and stripping of his varicose veins.A third patient was an obese, elderly

woman who worked in a nursing home. Shehad had a deep ulcer 7 cm. in diameter onthe anterior surface of her leg for a period ofover 5 years. The ulcer was due to varicosi-ties and previous thrombophlebitis. It hadbeen treated with various forms of compres-sion but to no avail. She had never beenhospitalized however. The ulcer healed com-pletely during a period of 5 weeks' treatmentwith the hydrostatic pressure stocking. Thispatient had extremely large legs as a resultof the obesity and edema. It was possible toadjust the stocking to fit her leg withoutspecial tailoring.The remaining patients in the series had

had ulcers of the lower extremity for rela-tively short periods of time. Their course oftreatment with the hydrostatic stocking wasuneventful. It was of interest to observe thatsecondary infection of the ulcers, even whensevere, cleared promptly with this form oftherapy. As noted above, antibiotic or otherlocal applications were not used.

All of the patients studied had subcutan-eous fibrosis, which was evident after dissipa-tion of the edema. The extent of this fibrosisvaried but it was marked in 4 of the patients.As with other forms of therapy for theseulcers, extensive subcutaneous fibrosis seemedto be associated with a slower rate of healingof the skin.

All of the patients apparently followedinstructions faithfully as to the use of thehydrostatic pressure stocking.

Pressures beneath the hydrostatic pressurestocking relative to those predicted from thelevel of the bladder in the axilla, averaged+1.2 (range -5.8 to +6.4) cm. of water meas-

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WOOD

FIG. 2. Diagrammatic illustration of the results ofjressure measurements beneath the hydrostatic pres-sure stocking from 2 points with the subject in 2

p~ositionls.

ured at 12 points beneath the stocking in therecumbent, sitting, and standing positions.The results obtained from 2 points beneath thestocking, in 2 positions are illustrated (fig. 2).The pressures were attained in 15 to 30 sec-

onds with each change of position of the sub-ject.The durability of the stocking was outstand-

ing in that the first patient referred to abovedemonstrated that it could be worn daily forat least a year without developing serious de-fects. Since numerous modifications of thestocking were made from the time he first be-gan its use, he did not wear any single stock-ilg for longer than 1 year. Three of thestockings have been filled with water for 2½/oyears and have shown no evidence of leaking.

DIscussIoNPatients with large ulcers of the leg caused

by chronic venous insufficiency often have tobe hospitalized before healing can be achieved.These ulcers apparently occur as a result ofthe high venous pressures in the leg associatedwith the erect posture. The high pressure isnot lowered significantly by walking, espe-

cially if the chronic venous insufficiency hasresulted from previous thrombophlebitis.3Presently available methods for treatment ofsuch patients on an ambulatory basis involvethe application of some form of compressionthat imparts essentially a constant pressure tothe ulcer. Occasionally, such methods of treat-mnent are quite effective, but in general the re-

sults are unpredictable. The reason for this

variation undoubtedly lies in the difficulty ofselecting or applying a single pressure to theextremity that would be reasonably effectivein all situations. For example, the externalpressure needed to counterbalance the venous

pressure that occurs at the level of the ankleof a patient 6-feet tall in the standing positionwould be approximately 130 em. of water.Ordinary elastic compression imparts about 25cm. of water pressure to the tissues. If apneumatic cuff12 were used to produce theneeded counterpressure of 130 cm. of water(96 mm. Hg), the patient would experience asignificant decrease in blood flow to the footwhen he assumed the sitting or supine position.This factor would be especially important ifthe patient were also suffering from arterialinsufficiency. The presence of arterial insuf-ficiency should lead the physician to use anyform of external compression cautiously.However, a pressurizing device that adjustsitself to counterbalance exactly the venouspressure of the leg is the safest of the avail-able methods for use in this circumstance.This form of compression reduces the effectivelocal arterial pressure to the same extent thatit reduces the effective local venous pressure,so that the effective gradient of pressure fromartery to vein would not be altered. If thepressure used on the leg greatly exceeded thatneeded to counterbalance local venous pres-sure, then it would result in a further decreasein effective local arterial pressure without afurther decrease in effective local venous pres-sure so that the arterial-to-venous gradient ofpressure would be reduced and consequently areduction of blood flow would occur.10

It is evident that it would be theoreticallyadvantageous to pressurize the leg of a pa-tient with chronic venous insufficiency andulceration of the skin from a column of waterwhose height is governed by the position of thepatient. It was possible to incorporate a hy-drostatically pressurized bladder into a stock-ing that could be worn for long periods oftime without serious inconvenience to the pa-tient. In fact several patients continued to beemployed in full-time occupations duringtreatment with this hydrostatic pressure

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HYDROSTATIC PRESSURE STOCKING

stocking. All of the patients treated with thisdevice had complete healing of the ulcers. Insome no further surgical procedures were in-dicated while others entered the hospital fordefinitive corrective surgery to the veins assoon as the ulcers were healed.The pressures actually reflected onto the

surface of the leg by the hydrostatic pressurestocking were, with minor variations, thosethat were predicted for the position of thepatient. Venographic studies of the lower ex-tremity have shown that external local com-pression of the leg results in a narrowing ofdeep as well as superficial veins.13 Directmeasurements of tissue pressure'4 and studiesof changes of venous volume with externalcompression'1O 15 have also indicated that thepressure is transmitted to the deep as well asthe superficial tissues.The results of the studies here reported sug-

gest that edema per se plays a decisive role inthe perpetuation of the ulcers of chronicvenous insufficiency. The primary effect of thehydrostatic pressure stocking would seem tobe one of maintaining a low transmural pres-sure within the veins and capillaries of theleg with a resultant diminution of edema for-ination. It is at least theoretically possible,however, that blood flow was improved withuse of this device. The lower effective venouspressure and the associated lower venous vol-ume15 might have allowed the leaflets of thesmall number"' of venous valves to come intoapposition, so that the normal "venous heart"mechanism operated to some extent to removeblood from the exercising calf. Finally, thebrief rises of venous pressure that occur withcoughing or with the Valsalva maneuver9might have been partially counterbalanced bythe hydrostatic pressure stocking.

SUMMARYA device is described that reflects counter-

pressure onto the surface of the leg in such a

way that the pressure is equivalent to that ofa vertical column of water between any pointon the leg and the level of the right atriumregardless of the position of the patient. Thisdevice, the hydrostatic pressure stocking,could be conveniently worn by patients.

Ten patients with ulcer of the skin of theleg due to chronic venous insufficiency usedthe hydrostatic pressure stocking as a solemeans of therapy while pursuing their usualdaily activities. All of the ulcers healed com-pletely with this treatment. The rate ofhealing was as rapid as might have been ex-pected with complete bedrest and elevation ofthe extremity.The hydrostatic pressure stocking does not

obviate the necessity of indicated surgery tothe local venous system. This device mayserve as a useful adjunct to surgery in thatan ulcer can be healed prior to entrance intothe hospital, thus reducing the chances ofsubsequent wound infections. The hydro-static pressure stocking appears to be of spe-cial value to patients who have chronic venousinsufficiency with repeated formation of ul-cers, when all forms of surgical therapy havebeen exhausted.

The results of these studies suggest that theprimary value of the hydrostatic pressurestocking in the treatment of ulcers of chronicvenous insufficiency is prevention of the for-mation of edema. Improved blood flow andcounterbalancing of sudden rises of localvenous pressure with coughing cannot beruled out as additional beneficial effects how-ever.

ACKNOWLEDGMENTThe author wishes to express his appreciation

to Mr. John E. Flagg and to the David Clark Com-pany for their aid in the design and for the con-struction of the hydrostatic pressure stocking.

SUMMARIO IN INTERLINGUAEs deseribite un dispositivo que reflecte un

contrapression contra le superficie del gambain un tal maniera que su effecto es le equiva-lente del effecto pressori de un columna deaqua inter non importa qual puncto super legamba e le nivello del atrio dextere, sin re-guardo al postura occupate per le patiente.Iste dispositivo, le calcea de pression hydro-static, pote esser portate per le patiente sininconveniente.Dece patientes con ulceres cutanee al gam-

ba causate per chronic insufficientia venoseusava le caleea de pressior hydrostatic como

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1WOOD)

le exclusive mesura therapeutic durante que

illes esseva ingagiate in lor usual activitatesquotidian. Sub iste tractamento omne le ul-ceres se sanava completemente. Le rapiditatedel sanation esseva lo que on haberea expectatesub le conditiones de allectamento completecon elevation del extremitate.Le calcea de pression hydrostatic non elimi-

na le necessitate de chirurgia local in le sys-

tema venose quando un tal es indicate. iblopote esser usate como adjuncto benefic al chi-rurgia, in tanto que un ulcere pote esser sanateante le hospitalisation del patiente de manieraque le risco de subsequente infectiones del vul-nere es reducite. Il pare que le calcea depression hydrostatic es de valor special in lecaso de patientes con chronic insufficientia ve-

nose in qui il ha repetite formation de ulcerse in qui omne formas de therapia chirurgicha essite exhaurite.Le resultatos de iste studios suggere que le

prime valor del caleea de pression hydrostaticin. le tractamento de ulceres causate per chro-Iic insufficientia venose es le prevention deomne formation de edema. Tamen, uii melio-ration del fluxo de sanguine e le equalisationde subite augmentos de local pression venose

quando le patiente tussi non pote esser negate

omo benefic effectos additional.

REFERENCES

1. ALLEN, E. V., BARKER, N. W., AND HINES,E. A., JR.: Peripheral Vascular Diseases.Philadelphia, W. B. Saunders, 1955.

2. BARROWS, D. W.: The Clinical Managementof Varicose Veins. New York, Hoeber-Harper, 1957.

3. POLLACK, A. A., TAYLOR, B. E., MYERS, T. T.,AND WOOD, E. H.: The effect of exercise

and body position on venous pressure atthe ankle in patients having venous valvu-lar defects. J. Clin. Invest. 28: 559, 1949.

4. WARREN, R., WHITE, E. AI., AND BELCHER,C. D.: Venous pressures in the saphenoussystem in normal. varicose, and postphle-bitic extremities: Alterations following fe-moral vein ligation. Surgerv 26: 435, 1949.

5. WHITE, E. A., AND WXARREN, R.: The walk-ing venous pressure test as a nimethod ofevaluation of varicose veins. Surgery 26:987, 1949.

6. H0JENSGARD, I. C., AND STURUP, H.: Venouspressure in primary and postthromboticvaricose veins: A study of the statics anddynamics of the venous system of the lowerextremity under pathological conditions. I.Acta chir. scandinav. 99: 133, 1949.

7. STURUP, H., AND H0JENSGARD, 1. C.: Venouspressure in the deep veins of the lowerextremity of patients with primary andpostthrombotic varicose veins: A study ofthe statics and dynamics of the venous sys-tem of the lower extremity under patho-logical condition. III. Acta chir. seandinav.99: 526, 1950.

8. HICKAM, J. B., MCCULLOCH, R. P., ANDREEVES, R. J.: Normal and impaired func-tion of the leg veins. Am. Heart J. 37: 1017,1949.

9. FELL, S. C., MCINTOSH, H. D., HORNSBY, A.T. HORTON, C. E., WARREN, J. V., ANDPICKRELT, K.: The syndrome of the chronicleg ulcer: The phlebodynamics of the lowerextremity; physiology of the venous valves.Surgery 38: 771, 1955.

10. LITTER, J., AND A.OOD, J. E.: The volume anddistribution of blood in the human legmeasured in vivo. I. The effects of gradedexternal pressure. J. Clin. Invest. 33: 798,1954.

11. POLLACK, A. A., AND WOOD, E. H.: Venouspressure in the saphenous vein at the anklein man during exercise and changes in pos-ture. J. Appl. Physiol. 1: 649, 1949.

12. SCOTT, W. J. M., AND RADAKOVICH, M.: Ven-ous and lymphatic stasis in the lower ex-tremities: I A test for incompetence in theperforating veins: II A simple method ofadequate control. Surgery 26: 970, 1949.

13. STANTON, J. R., FREIS, E. D., AND WILKINS,R. W.: The acceleration of linear flow inthe deep veins of the lower extremity ofman by local compression. J. Clin. Invest.28: 553, 1949.

14. LANDOWNE, M., AND KATZ, L. N.: A critiqueof the plethyssmographic method of measur-ing blood flow in the extremities of man.Am. Heart J. 23: 644, 1942.

15. WOOD, J. E., AND ECKSTEIN, J. W.: A tandemforearm plethysmograph for study of acuteresponses of the peripheral veilns of man:The effect of environmental and local tem-perature change and the effect of poolingblood in the extremities. J. Clin. Invest.37: 41, 1958.

16. VAN CLEAVE, C. D., AND HOLMAN, R. L.: Apreliminary study of the number and dis-tribution of valves in normal and varicoseveins. Am. Surgeon 20: 533, 1954.

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J. EDWIN WOODVenous Insufficiency

A Hydrostatic Pressure Stocking for the Treatment of Ulcers due to Chronic

Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 1959 American Heart Association, Inc. All rights reserved.

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