—Most injured veins can be tied in situ and their function left to the collateral circulation. Fear is sometimes felt about the axillary and the femoral veins, and serious discussions have arisen as to whether amputation might be called for should these large channels be so injured as to be made useless. Experience has shown that either of them may be ligated, with nothing worse than temporary edema of the limb beyond. Should there then occur, by accident or during an operation, an opening of these venous trunks one may apply the ligature, if necessary. Before resorting to this, however, one may consider the advisability of the application of a fine suture to the margins of the wound in the vein, which has become a standard procedure, or, if the opening be small, and it can be seized with a hemostat, it may be left in situ for two or three days, closing the wound around it, and so supporting and protecting the part with dressings that it shall not be disturbed. A small forceps or its equivalent may thus be left upon a cranial sinus, a jugular, subclavian, axillary, femoral, or other vein without jeopardizing the result.
VARICES AND PHLEBECTASES.
The term phlebectasia implies an extensive affection of a portion of the venous system, characterized by more or less uniform enlargement of all its veins. A similar involvement of isolated veins is usually spoken of as varix. These conditions may be congenital or acquired. [Fig. 182] illustrates a congenital varicose condition occurring in a lad aged sixteen years. Such a lesion may be explained by congenital defect in some of the deeper veins, thus compelling the venous blood to return through the more superficial channels. These congenital lesions are more common in the lower extremities, but may be seen in all parts of the body. Varices, also, by virtue of their exciting and contributing causes, are most common in the lower extremities and in the lower venous terminals, as in the scrotum, the rectum, etc. Acquired varices usually imply previous lesion in the vein walls, sometimes inflammatory, sometimes toxic. The walls of the veins thus become at first atrophied, this condition being often followed by irritative hyperplasia, by which finally the veins become thickened and strengthened, and sometimes calcified. The enlargements are irregular and sacculations frequently form. In such sacculi thrombi may occur and be followed by calcification, the resulting concretions being known as phleboliths. These can often be recognized through the skin in old and chronic cases. Sometimes adjoining sacculi become confluent and there forms what is called an anastomotic varix. By such communications cavernous conditions are produced which, when placed subcutaneously, lead to peculiar and distinctive tumor formations.
Fig. 182
Congenital varices. (Park.)
As already stated, the tendency to varices is indirectly the result of man’s assumption of the upright position, by which greater stress is placed upon the valves and the lower veins than they are prepared to bear. Naturally these conditions occur often in those who are constantly engaged in hard work upon the feet. Varices, then, are lesions, not so much of the leisurely and sedentary as of the active and working classes. Anything which predisposes to venous stasis may be regarded as a contributing cause—thus their relations with weakened hearts and obstructed lungs are indirect, but positive. Many women suffer in this way as the consequence of their first pregnancy, with its pressure upon the pelvic veins; while tight garters, corsets, and belts also predispose to overloading of the lower veins. Slight but almost permanent causes of this kind, through the influence of gravity, thus produce varices in the course of time.
To varices in certain locations have been given special names. To such a dilatation of the spermatic and pampiniform plexus has been given the name varicocele. When the hemorrhoidal veins are involved the condition is known as hemorrhoids or piles. The former is often credited with being due to the anatomical arrangement of the left spermatic vein, through which blood is not as directly poured into the vena cava as on the right side, while the relation of chronic constipation, with its obstruction to the circulation in the rectal walls, will account for many cases of hemorrhoids, and the disturbance implied by the term cirrhosis of the liver will furnish an explanation for many others. A similar condition in the esophageal veins has given rise to the term esophageal hemorrhoids. Most indicative and extraordinary expressions of closing of deep circulation may be seen in some instances of intrathoracic and intra-abdominal diseases, i. e., cases in which the superficial veins of the chest and thorax become remarkably enlarged. Such expressions as these are to be regarded as natural efforts to obviate a difficulty, and no attempt should be made to eradicate such varices.
Symptoms.
—In cases requiring surgical intervention, varicose veins present the following features, which are particularly indicative; they not only enlarge in diameter but elongate, and consequently have to assume a tortuous arrangement to accommodate their increased length; they cause a constant sense of fulness and discomfort, which often amounts to actual pain, especially after laborious effort. This pain is due to the distention of the venous trunks, to pressure upon cutaneous nerves, and often to disturbances of nutrition. In fact, nutrition is so often disturbed as to be accompanied by skin lesions, which begin as eczema and terminate in extensive ulcerations. So frequent is this association, and so distinctive its type, that such ulcers are frequently referred to as varicose. If the term be used to imply the association it perhaps may stand; if intended to typify a peculiar type of ulcer it is objectionable, as the ulcer itself is simply such as may happen on any surface whose nutrition is more or less perverted.