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.

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]

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.

In milder cases, where no single large dilated vein seems to call for extirpation, it may suffice to practise Schede’s operation alone. Experience has taught this fact, that in dealing with extensive varices the surgeon is more likely to err on the side of leniency than on that of thoroughness.

VENOUS ANGIOMAS.

These have already been mentioned in the chapter on Tumors as constituting one variety of the angiomas. Many of them are of congenital origin. In many instances they produce erectile tumors. They frequently occur in the liver, in the thyroid, and other internal organs, as well as on the body surface.

A venous tumor, composed of good-sized veins, distended perhaps far beyond their normal capacity, constitutes a compound varix, of which the best expression is a hemorrhoid or a varicocele. Another form is composed almost entirely of capillary veins, which are increased not only in size but also in number. These constitute the growths called “mothers’ marks,” “strawberry growths,” etc. Technically they are venous nevi, which vary in size from trifling lesions to large tumors of varying shapes. These growths are always most conspicuous about the hands and face, because these are the visible parts of the body. They may, however, occur at any point, but mainly about the face and the orbit. A diffuse form, whose area may be almost unlimited, but usually circumscribed, is that called “port-wine mark,” which occurs more frequently about the face. It has been attributed to mental impressions during pregnancy, but there seems little to justify this view. The affected surface is sometimes pigmented and generally more hairy. Surface markings of this kind may accompany that form of neuroma described as plexiform neuroma. Fig. 183, from Holloway, illustrates another form of congenital growth of this kind. These growths rarely occur in the nasopharynx, where they not only obstruct but are sources of actual danger from hemorrhage.

Treatment.

—The most satisfactory treatment of a limited growth of this kind is excision, especially if this can be made at an early age. The resulting scar will be smaller, the healing more prompt, and the result in every way better. When excision seems impracticable electrolysis should be employed, one or both poles of a galvanic battery of six to ten cells being connected with needles, which are inserted directly into the growth, and whose position is constantly changed, so that the coagulating effect of the electric current may be equably distributed throughout the growth. Occasionally the growth may be so shaped as to permit of ligature, and it is best employed either with or without the use of a needle, after which it may be excised or will slough off. This is essentially one method of treating external hemorrhoids. Methods by injection of coagulants are all open to serious objection, are hazardous, and should be abandoned. A port-wine mark may be sometimes treated by a tattooing process, which should, however, be practised with strict antiseptic precautions. Electrolysis may also be practised over a small area at a time. The more destructive method, by use of the cautery, is likely to leave scars almost as conspicuous as the original condition. Occasionally a lesion of this kind will be so shaped and placed as to justify excision with an autoplastic operation.