+DISEASES OF VEINS+
Varicose veins are unnatural, irregular, and permanently dilated veins
which elongate and pursue a tortuous course. This condition is very
common, and twenty per cent. of adults exhibit it in some degree in
one region or another.
The causes of varicose veins are obstruction to venous return, and
weakness of cardiac action, which lessens the propulsion of the blood
stream.
Varicose veins may occur in any portion of the body, but are chiefly
met with on the inner side of the lower extremity.
Varix in the leg is met with during and after pregnancy, and in
persons who stand upon their feet for long periods.
It especially appears in the long saphenous vein, which, being
subcutaneous, has no muscular aid in supporting the blood-column and
in urging it on. The deep as well as the superficial veins may become
varicose.
Varicose veins are in rare instances congenital; they are most often
seen in the aged, but usually begin at the ages of twenty to forty.
A vein, under pressure, usually dilates more at one spot than at
another, the distention being greatest back of a valve or near the
mouth of a tributary. The valves become incompetent and the dilatation
becomes still greater. The vein wall may become fibrous, but usually
it is thin, and ruptures. The veins not only dilate, but they also
become longer, and hence do not remain straight but twist and turn
into a characteristic form.
Varicose veins are apt to cause edema, and the watery elements in the
tissues cause eczema of the skin. When eczema is once inaugurated,
excoriation is to be expected. Infection of the excoriated area
produces inflammation, suppuration, and an ulcer.
The skin over varicose veins in the legs is often discolored by
pigmentation due to the red cells having escaped from the vessel and
then being broken up.
The tissues around a varicose vein become atrophied from pressure, and
often a very large vein will be in evidence whose thin walls are in
close contact with the skin, and in this condition, rupture and
hemorrhage are probable. Varicose veins are apt to inflame and
thrombosis frequently occurs.
+Treatment.+ The treatment of varix may be palliative or curative, but
whichever is followed, endeavor first to remove the cause.
In palliative treatment, attend to the general health, keep up the
force and activity of the circulation, and prevent constipation.
Recommend the patient to exercise in the open air and to lie down, if
possible, every afternoon. Locally, in varix of the leg, order a
flannel bandage to support the vein and drive the blood into the
deeper vessels which have muscular support. (For technic, see chapter
on bandaging).
The curative or operative treatment of varicose veins consists of
performing a resection of the internal saphenous vein of one or two
inches, near the saphenous opening into the femoral. This is known as
the _Trendelenburg_ method. About 90 per cent of all cases can be
cured by this method. The operation can be performed under local
anesthesia and presents no difficulties.
Another procedure is known as _Schede’s_ method. This consists of
making a circular incision around the leg just below the knee joint,
and in tying all the superficial veins thus exposed.
_Mayo’s_ operation consists of the total extirpation of the internal
saphenous vein from the saphenous opening to the internal malleolus. A
small incision is made high up, and at a distance of from 8 to 10
inches, a second incision is made, and in this manner the entire vein
is removed by making several incisions.
The patient should remain in bed about three weeks following an
operation of this kind and afterwards an elastic stocking, or an ideal
bandage, should be worn for a considerable time.
+Phlebitis+, or inflammation of a vein, may be plastic or purulent in
nature. Plastic phlebitis, while occasionally due to gout, or to some
other constitutional condition, usually arises from a wound or other
injury, from the extension to the vein of a perivascular inflammation,
or, in the portal region, from an embolus.
Varicose veins are particularly liable to phlebitis. When phlebitis
begins, a thrombus forms because of the destruction of the endothelial
coat, and this clot may be absorbed or organized.
+Suppurative Phlebitis+ is a suppurative inflammation of the vein,
arising by infection from suppurating perivascular tissues (_infective
thrombophlebitis_). It is most frequently met with in cellulitis or
phlegmonous erysipelas, but there are a great many other causes.
A thrombus forms, the vein wall suppurates, is softened and in part
destroyed, and the clot becomes purulent. No bleeding occurs when the
vein ruptures, as a barrier of clot keeps back the blood stream. The
clot of suppurative phlebitis cannot be absorbed and cannot organize.
Septic phlebitis causes pyemia, and the infected clots of pyemia cause
phlebitis. The symptoms of phlebitis are pain, which is at once felt
in the limb along the track of the inflamed vein, and tenderness along
the same area; the overlying skin is red, hot, and tender, and the
lymphatic nodes in the groin swell; there is marked edema, but the
inflamed venous cords can be readily felt. The constitutional
disturbance is marked; rigors and high temperature, 103°F. to 105°F.
(remittent type), are followed by profuse sweats. The general
condition, facies and anxiety, dry and parched tongue, delirium and
general distress, at once directs attention to the infectious nature
of the trouble. The leucocyte count will show a marked increase in the
number of polynuclears.
+Treatment.+ The treatment of phlebitis may be classified into
preventive and curative, the latter being subdivided into (_a_),
general or symptomatic, and (_b_), local or surgical.
The preventive treatment is summed up in the word asepsis. The
influence of asepsis in the management of wounds has completely
revolutionized surgical practice, and the old fatal types of pyemia
and septicema have now practically vanished.
Septic and pyogenic phlebitis still remain as consequences of
accidental wound contaminations and as a penalty for the neglect of
surgical cleanliness.
Prophylatic measures, by the use of internal remedies which diminish
the coagulability of the blood, such as Wright’s citric acid
treatment, are recommended for the prevention of thrombosis.
Antitoxins have not proven to be of benefit in this condition.
The curative treatment may be symptomatic, local, constitutional, or
surgical. The constitutional treatment is directed to the general
cause, if possible, as in the gouty, rheumatic, syphilitic, and
chloritic cases; beyond this, there is no specific treatment. The
antistreptococcal and staphylococcal sera are usually prescribed in
the septic forms, but thus far, more as a forlorn hope than with the
expectation of accomplishing any definite results. The symptomatic
treatment, on the other hand, is always indicated to diminish pain, to
support and strengthen the circulation, and to favor elimination. The
main reliance is to be placed upon the local treatment, combined with
good nursing, appropriate food, and moderate stimulation.
The local treatment is summed up in the following indications: (_a_),
immobilization and absolute rest of the affected limb; (_b_), elevated
position of the foot of the bed or of the limb to favor the drainage
of the venous current toward the trunk. The limb should be covered
with cotton batting and bandaged, over a gutter-splint of cardboard,
extending from the foot to the thigh, to immobilize the knee. In the
superficial inflammations, with much redness and heat, an even layer
of any of the kaolin mixtures may be applied between thin layers of
gauze, like an antiseptic poultice, over the entire extremity, and
especially over the inflamed parts. A saturated watery solution of 25
per cent. ichthyol, painted over the entire surface will also prove
decidedly beneficial in cases complicated with lymphangitis. Unguentum
Crede, mercurial ointment, and the so-called resolvent lotions have
been tried, but none of these can compare in their beneficial effect
with kaolin poultices, with or without ichthyol, or the liberal
application of broad compresses, thoroughly saturated with a weak lead
and opium lotion, which latter acts not only as a local astringent,
but as a marked sedative. Immobilization and rest should be maintained
for a month or more.
+Operative Treatment.+ The operative treatment of acute septic
thrombophlebitis has in view three indications, and the procedures
adopted must vary according to these: (1) ligation of the vein between
the thrombotic focus and the uninfected vein on the cardiac side, in
order to obstruct the further advance of the infection, and thus
prevent the entrance of septic emboli into the circulation; (2)
removal of the primary focus of infection by direct incision into the
veins, evacuation of the septic thrombus and drainage; (3) extirpation
of the infected veins with the contained clot and septic contents.