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.