The most common causes of varicosities in the lower extremities are previous lesions, such as phlebitis following typhoid, injuries of the limbs or trunk, the pressure of tumors, fecal accumulations, garters or belts, laborious work in the upright position, and the possible complications of all cases from variation in the original anatomical arrangement of veins and their valves; pregnancy also should be added to this list.
The condition is rare in early life. Liability to it increases with age. Varices rarely occur in the upper limbs in connection with certain occupations or athletic sports, e. g., baseball and tennis.
The measure of the distention of veins can often be taken by the sensation of fulness and muscle cramp. In few surgical lesions do appearances give as much aid in diagnosis. This is particularly true of superficial varices. Varicosities of the deeper veins maybe suspected when patients complain of discomfort, pain, cramp, and swelling of the feet after hard work.
Varices would rarely lead to ulceration were it not for the superficial infections incurred in many obvious ways—sometimes by the finger-nails of the individual, who is constantly tempted to scratch or rub the area in which he feels such incessant discomfort.
Treatment.
—Suitable treatment of varices of the internal veins, varicocele, hemorrhoids, etc., will be indicated in its proper place. In this chapter only varices of the extremities will be considered. When a tendency to the varicose condition is noted early, and a cause can be discovered, removal of the cause may be all that is needed. When the condition is well established, and yet not sufficiently prominent to justify radical treatment, it should consist largely in support by bandages or elastic stockings, applied discriminatingly, with sufficient pressure to prevent undue distention and not sufficient to cause edema. It frequently affords much relief and prevents aggravation of the condition; on the other hand, once the veins become accustomed to this support they yield more readily upon its withdrawal, and the treatment by gentle constriction once begun, which is sufficient for many cases, can rarely be discontinued, even after a lapse of time.
A maximum of rest and elevation of the limb are requisite in the non-operative treatment of varicose veins. The compression exercised by elastic stockings is of only temporary benefit, and is simply such an assistance as is a crutch to a cripple. The less the patient remains upon the foot and the less he takes hot baths or indulges in other relaxing measures the better. Cold shower or tub baths are far preferable, with massage of the deeper muscles, the large veins being avoided. Such a patient should never walk slowly, but always rapidly, and rest as soon as fatigued. All diathetic conditions should receive attention.
When it is not possible to early and speedily remove the existing cause there is but one cure for varices, and that is by radical surgical treatment. A generation ago this was effected by the injection into the veins of perhaps one of the iron salts, in order to produce artificial and instantaneous thrombosis, by which later occlusion of the vein could be induced. The coagulating effects were decided, and so also were the effects of the germs introduced at the same time, in the absence of ordinary antiseptic precautions. Thus it resulted that the mortality, even after this trifling procedure, was tremendous and led to its abandonment. When it had been demonstrated, through Lister’s achievements, that the surgeon could be clean about such work, it was learned also that veins could be more radically treated than had been previously realized. With the advent of the antiseptic era came more effective and extensive operations upon veins. Now we know that with strict asepsis they can be handled with absolute impunity, and open methods of treatment have replaced the subcutaneous. No hesitation is at present felt in exposing the veins at one point, or numerous points, and applying ligatures; these, however, have been found to be less effective than a long incision made over a vein, with its complete extirpation. Thus the long internal saphenous should nearly always be excised, though it take an incision twenty inches in length, in order to take off the weight of its column of blood. It is ordinarily a simple matter to clamp and tie each branch as it is divided, and, after removal of the principal trunk, to bring together the entire incision with subcutaneous or continuous sutures. In the same way numerous incisions may be made in the leg. It is possible, however, to meet with so many enlarged veins that the surgeon may feel that he cannot thus eradicate each one. In such cases it is my custom to extirpate the principal trunk or trunks involved above, and then to combine this with Schede’s suggestion to completely or partly circumcise the leg, below the knee, down to the deep fascia, cutting across every vein and tying on each side those which bleed to any extent. After all these veins are ligated the incision is usually brought together again, as above. By this means all communication between the subcutaneous veins above and below the line of incision is cut off. Wound healing is accompanied by a temporary edema of the foot and leg, especially when these are held down, and by more or less numbness of the skin due to division of the cutaneous nerves; but circulation and nerve supply both rearrange themselves in time, and the result is usually satisfactory.[28]
[28] Extirpation of the Internal Saphenous.—Keller has quite recently suggested a new method of extirpating these varicose veins without extensive scarring. He exposes the vein at two points a considerable distance apart, and ties above and below after separating it from its surroundings. The vein is then cut below the proximal end, the upper end of the section to be removed split and a strong ligature tied to it, care being taken to include no more tissue in the ligature than will pass through the lumen of the vessel. Then from the lower end a wire loop or probe is passed upward, a ligature is threaded into its eye and the probe is then withdrawn, carrying the ligature, after which traction is made upon the latter, the edges of the vein being inverted into its own lumen, it being thus extirpated by being turned inside out and withdrawn from its sheath. With the internal saphenous, when a slight puckering is seen about midway between the incisions, indicating that the anterior branch of the vessel has been reached, a third incision is made, the branch is ligated and divided, and then the traction renewed until the vein is entirely pulled through the lower opening. Several cases thus treated have been very successful.
Should ulcer, i. e., the so-called varicose ulcer, be present, it may also be attacked radically, and at the same time completely, by excising the affected area, with its indurated border, down to the level of the deep fascia, and covering the surface thus denuded with Thiersch skin grafts from some other portion of the body. Should such an ulcer require treatment after this fashion it is best to attend to excision of the infected area first, in order to clear away all material which might harbor germs. The usual procedure, then, should be excision of the ulcer, extirpation of the veins, to be concluded by skin grafting. A limb thus radically treated should be included in a comfortable dressing, and then be affixed to some splint or other device by which absolute rest and repose may be maintained.