Treatment.—At best the treatment of varicose veins is only palliative, as it is obviously impossible to restore to the vessels their normal structure. The patient must avoid wearing anything, such as a garter, which constricts the limb, and any obvious cause of direct pressure on the pelvic veins, such as a tumour, persistent constipation, or an ill-fitting truss, should be removed. Cardiac, renal, or pulmonary causes of venous congestion must also be treated, and the functions of the liver regulated. Severe forms of muscular exertion and prolonged standing or walking are to be avoided, and the patient may with benefit rest the limb in an elevated position for a few hours each day. To support the distended vessels, a closely woven silk or worsted stocking, or a light and porous form of elastic bandage, applied as a puttee, should be worn. These appliances should be put on before the patient leaves his bed in the morning, and should only be removed after he lies down at night. In this way the vessels are never allowed to become dilated. Elastic stockings, and bandages made entirely of india-rubber, are to be avoided. In early and mild cases these measures are usually sufficient to relieve the patient's discomfort.
Operative Treatment.—In aggravated cases, when the patient is suffering pain, when his occupation is interfered with by repeated attacks of phlebitis, or when there are large pouches on the veins, operative treatment is called for. The younger the patient the clearer is the indication to operate. It may be necessary to operate to enable a patient to enter one of the public services, even although no symptoms are present. The presence of an ulcer does not contra-indicate operation; the ulcer should be excised, and the raw surface covered with skin grafts, before dealing with the veins.
The operation of Trendelenburg is especially appropriate to cases in which the trunk of the great saphena vein in the thigh is alone involved. It consists in exposing three or four inches of the vein in its upper part, applying a ligature at the upper and lower ends of the exposed portion, and, after tying all tributary branches, resecting this portion of the vein.
The procedure of C. H. Mayo is adapted to cases in which it is desirable to remove longer segments of the veins. It consists in the employment of special instruments known as “ring-enucleators” or “vein-strippers,” by means of which long portions of the vein are removed through comparatively small incisions.
An alternative procedure consists in avulsing segments of the vein by means of Babcock's stylet, which consists of a flexible steel rod, 30 inches in length, with acorn-shaped terminals. The instrument is passed along the lumen of the segment to be dealt with, and a ligature applied around the vein above the bulbous end of the stylet enables nearly the whole length of the great saphena vein to be dragged out in one piece. These methods are not suitable when the veins are brittle, when there are pouches or calcareous deposits in their walls, or where there has been periphlebitis binding the coils together.
Mitchell of Belfast advises exposing the varices at numerous points by half-inch incisions, and, after clamping the vein between two pairs of forceps, cutting it across and twisting out the segments of the vein between adjacent incisions. The edges of the incisions are sutured; and the limb is firmly bandaged from below upwards, and kept in an elevated position. We have employed this method with satisfactory results.
The treatment of the complications of varix has already been considered.
Angioma[4]
[4] In the description of angiomas we have followed the teaching of the late John Duncan.
Tumours of blood vessels may be divided, according to the nature of the vessels of which they are composed, into the capillary, the venous, and the arterial angiomas.